Download To allow for insertion of the catheter.

The Placement and Care of all indwelling intravenous and subcutaneous
catheters Version 1
Type of Document
Trust Policy
Code:
Policy Sponsor
Lead Executive
Director of Nursing, Midwifery and Governance
Director of Nursing, Midwifery and Governance
Recommended by:
Task & Finish Group
Date Recommended:
24 August 2012
Approved by:
Clinical Performance Council
Date Approved :
Author(s):
10 September 2012
Nurse Consultant Critical care
Outreach/MET Nurse lead.
Date issued:
1 October 2012
Review date:
1 October 2015
Target audience:
Document purpose
All clinical staff
To ensure indwelling intravenous and subcutaneous devices are inserted
and managed appropriately
Refer to induction, mandatory and risk management training policy –
training needs analysis. (2011)
Training requirements
Associated documents
1. ANTT (Aseptic non-touch technique) (2008). www.antt.co.uk
and Key References 2. Ingram P and Lavery I (2007) Peripheral Intravenous Cannulation –
Safe Insertion and Removal Technique. Nursing Standard 22,1.44-48.
3. Department of Health (2007). Saving Lives: High Impact Intervention No
1. Central Venous Catheter Care Bundle (see references below)
4. North Bristol NHS Trust (2009) - Hypodermoclysis Policy.
5. Hand Decontamination Policy Infection Control Manual Chapter 21
http://nww.sthk.nhs.uk/library/documents/chapter21handdecontamination
.pdf
Financial Implications
Key Words
Equality
assessment
IV lines, Intravenous lines, Intravascular catheter, Peripheral line,
Peripherally Inserted Central Catheter, PICC, Hickman, Central Venous
Catheter, CVC, Subcutaneous needle, hypermoclysis, Central Vascular
Access Devices, CVAD.
impact Low
Page 1 of 65
Consultation, Communication
Consultation Required
Authorised By
Analysis of the
effects on equality
Low impact
External Stakeholders
Trust Staff
Consultation via
Intranet
Date Authorised
Comments
1 October 2012
Start date: N/A
End Date: N/A
Policy Implementation Plan
Describe the Implementation Plan for the Policy
Timeframe
implementation?
The policy will be published on the intranet…
1 October 2012
Key Performance
How will the
Monitored?
KPI
Line infection rates
ANTT nurse specialist
for
RAG
Who is responsible for delivery?
G
Directorate Manager Critical Care Unit
be Which Committee
Frequency
will Monitor this
Review
KPI?
Hospital
Infection Annual
Prevention
Committee
of Lead
DIPC
Performance Management of minimum NHSLA processes for this policy. (If policy is not an NHSLA general standard requirement or
CNST maternity requirement add in N/A not applicable)
Learning from Experience
Page 2 of 65
Minimum requirement Process
for Responsible
Frequency
to be monitored
monitoring e.g. individual/
group/ monitoring
audit
committee
N/A
N/A
N/A
N/A
of Performance management of minimum requirements.
Responsible individual/ group/ committee (plus frequency of
review/ timescales) for:
Review of results
Development
and Monitoring
of
update of action action plan and
plan
implementation
N/A
N/A
N/A
Who is responsible for producing action plans if deficits in Which Committee will monitor these action Frequency of Review
KPI’S and associated processes identified
plans
DIPC
Hospital Infection Prevention Committee
How does learning occur?
Who responsible for implementing
disseminating learning information
Archiving including retrieval of archived document
Annual
and Frequency
By whom will policy be archived and retrieved
Document Version History
Date
Version
Version
Summary of key changes
Author Designation
1 October 2012
1
This policy is an amalgamation of and
Nurse Consultant Critical care
replaces the following policies:
Outreach/MET Nurse lead.
Procedure for the insertion and management
of peripheral intravenous cannula
Procedure for the Placement of a Peripherally
Inserted Central Catheter
Guidelines for Management, Maintenance and
Removal of CVAD
Procedure for the administration of fluid via the
sub-cutaneous route (hypodermoclysis)
Page 3 of 65
Contents
Page
1
Introduction and scope of the document
2
Indications for insertion of indwelling devices
3
Complications of indwelling devices
4.1
4.11
Placement of peripheral intravenous catheters
Education and supervision
All staff new to cannulation
Newly appointed Registered Nurses/Midwives, Assistant Nurse
Practitioners who have previously undertaken cannulation at another
Trust
Newly appointed Medical Support Workers and Health Care Assistants
(Bands 2&3) who have previously undertaken cannulation at another
Trust
Supervisors Responsibilities
Practitioner Responsibilities
Medical Staff
Registered Nurses/Midwives
Assistant Practitioners /Health Care Assistants and Medical Support
Workers
Staff working in A&E
General principles and additional information for peripheral
cannulation
Environment
Sites for intravenous access
Type/Size of cannula
Blood samples from devices
Immediate post insertion of a vascular access device
Procedure
Equipment
4.12
4.13
4.14
4.2
4.21
4.22
4.23
4.3
4.31
4.32
4.33
4.34
Placement of a subcutaneous needle
Aim
General principles
Indications for use
Performed by
Infusion sites
Procedure
Equipment
Placement
Placement of a Peripherally inserted Central Catheter (PICC)
Indications for use
Environment
Education and supervision
Supervisors Responsibilities
Equipment
Procedure
7
8
8
9
10
16 – 18
19
20
21-28
Page 4 of 65
Page
4.4
4.41
5
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
6
Placement of a Central Venous Catheter (CVC)
Indications for use
Environment
Equipment
Procedure
29
30 – 33
Management of indwelling devices
General principles for the maintenance and management of vascular
access devices
Aseptic non-touch technique (ANTT)
Needle free devices
Intravenous giving sets
Observation
Indwell times for peripheral cannulae
General rules for peripheral cannula care
General rules for subcutaneous needle care (hypoodermoclysis)
Management of the infusion site
Fluid type and method of administration
Method of administration
Rate of administration
Absorption of subcutaneous fluids
General Rules for Central line care
Changing the dressing on a vascular access device site
Principles
Type of Dressing
Procedure
Equipment
Flushing central vascular access device
Flushing solution and methods
Procedure
Equipment
Blood sampling from Central Vascular Access Devices(CVAD)
Principles
Procedure
Equipment
Unblocking Central Vascular Access Device (CVAD)
Principles
Procedure
Equipment
Removal of peripheral intravenous Cannula and subcutaneous
needle
Procedure
Equipment
Removal of Central Vascular Access Devices (CVAD)
Variations
Equipment
Procedure
Bibliography
34
35
36
37
37 - 39
39
41
43
44
45
48
Page 5 of 65
Page
Appendix A
Glossary of abbreviations
Appendix B
Developing the scope of professional practice
Appendix C
Observational Assessment of Competency: Inserting of a peripheral
Cannula
Appendix D
Observational Assessment of Competency: Drawing up and
administration of sodium chloride for flushing for non-registered staff
Appendix E
Assessor Guidance, knowledge assessment
Appendix F
Assessment Record for inserting a peripheral cannula
Appendix G
Reflective Evidence of Continuing Professional Development
Appendix H
Types of central access devices and sites of insertion
Appendix I
Visual Infusion Phlebitis Score Chart (VIP)
Appendix J
Clinical Competencies Acquisition for Inserting PICC lines
Appendix K
Record of continuous assessment to perform PICC placement
Appendix L
Peripheral cannulation insertion record
Appendix M
Persistent withdrawal occlusion algorithm
Appendix N
CVAD score sheet
49
50
51
53
55
56
57
59
60
61
62
63
64
65
Page 6 of 65
1. Introduction and scope of the document.
Safe technique and high standards of hygiene are essential to managing intravenous and
subcutaneous devices. This policy outlines a standard evidence based approach to inserting and
maintaining different indwelling catheters.
This policy applies to all staff responsible for inserting and maintaining devices and includes:
Medical staff, Registered General Nurses (Levels 1 & 2), Midwives, Assistant Practitioners (band 4),
Senior Health Care Assistants (Band 3), Medical Support Workers and Health Care Assistants
(Band 2)
2. Indications for intravascular cannulation
It is estimated that approximately 60% of hospital inpatients annually undergo peripheral
intravenous cannulation in order to receive therapeutic intravenous medication (Morris 2008).
Intravenous cannulation may normally be performed for one of the following reasons:






Replacement of fluids.
Administration of drugs.
Transfusion of blood products.
Parenteral nutrition.
Emergency situation i.e. cardiac arrest
Anticipation of potential deterioration of condition e.g. post myocardial infarction.
3. Complications of indwelling devices







Infection – entry site and bloodstream
o Intravenous therapy offers a ready means of allowing direct bacterial access to the
patient’s vascular system, as the normal skin defence system is bypassed. Serious
infection, possibly resulting in death, may result.
o It is therefore essential that strict aseptic technique be adhered to at the time of
intravenous cannulation or subsequent manipulation of the intravenous system.
Air embolism
Thrombophlebitis (inflammation of vein) due to infection, mechanical or chemical irritation
of the vein.
Infiltration/Extravasation
Thrombus Formation
Adverse Reaction to blood/blood products/drugs.
Arterial Puncture
Additional complications associated with centrally inserted catheters




Catheter Malposition
Pneumothorax/Haemathorax
Cardiac Arrythmias
Difficult catheter removal/Catheter Embolus
Page 7 of 65
4.1 Placement of peripheral intravenous catheters

Nerve injury and irritation
4.11 Education and Supervision
All staff new to the skill of peripheral cannulation must:
 Attend the trust study day on ‘Peripheral Intravenous Cannulation’ / Undergraduate Medical
staff to complete relevant training program delivered by the undergraduate education team.
 Complete a minimum of 10 successful supervisions of practice within a time frame of 12 weeks
from attending the study day and complete the ‘Peripheral Intravenous Cannulation’ competency
sheets (Appendix F). / Following the attendance of cannulation training Medical undergraduates
may undertake the task of peripheral cannulation but only with direct supervision by a
practitioner whom has been deemed competent within the skill of peripheral cannulation.
 Demonstrate the necessary knowledge and skills to practice unsupervised.
Newly appointed members of Nursing/Midwifery



Staff need to be assessed as competent with ANTT prior to commencing on a peripheral
cannulation course.
Staff who have practised Peripheral Intravenous Cannulation at another trust and have
previously attended a study day/update on Peripheral Intravenous Cannulation’ within the
past 5 years will be required to complete a period of supervision as per 4.11, points 2 – 4
above.
If 5 years have lapsed since attending the session the candidate must attend the trust
session at the earliest opportunity. Supervised practice can commence but if at any time the
supervisor/or the candidate feel that they are not demonstrating the required knowledge and
skills they must abandon supervised practice and only recommence practice once they have
attended the trust session.
Newly appointed Medical Support Workers, Health Care Assistants (Bands 2 & 3) and
Assistant Practitioners (Band 4), who have previously undertaken ‘Peripheral Intravenous
Cannulation’ at another trust.
This group of staff will be required to attend the trust ‘Peripheral
Intravenous Cannulation’ study day before commencing the period of supervision as per Section
4.12 Supervisors Responsibilities





Supervisors must be either: a Registered General Nurse/Midwife, Assistant Practitioner or
Doctor competent at cannulation.
Supervisors must directly supervise the practitioner when they perform cannulation until they
have been assessed as competent to practice without direct supervision.
Competence to practice without direct supervision is only achieved following a minimum of 10
competent successful cannulations. This is for all the following staff; Registered Nurses,
Midwives, Assistant Practitioners, Medical Support Workers and Health Care Assistants (Bands
2 & 3).
Supervisors must complete and sign the record of supervision following each cannulation
attempt.
Supervisors must document any recommendations for further supervised practice and/or
repeating the cannulation study day on the record of supervision form. The rationale for the
recommendations must be included. N.B. Competence in the procedure is described as
insertion of the device and the checking of the patency without the intervention of the supervisor
Page 8 of 65


at any point during the process.
Any practitioner (as named in point 1) competent at cannulation can provide supervised
practice; however, it must be a designated supervisor who provides the majority of the
supervised practice for the period of supervision (at least 50%). This is to ensure continuity of
the learning experience.
If the period of supervision exceeds 12 weeks it is up to the discretion of the designated
supervisor, ward manager and candidate as to whether to extend the supervised period or
recommence the 10 supervisions.
4.13 Practitioner Responsibilities
Medical Staff
 The insertion of peripheral intravenous cannulae is a shared responsibility between nursing
and medical staff. When a Doctor is requested to insert a cannula by a member of the
nursing staff, it should be automatically seen as an appropriate task for the Doctor to perform.




It is stressed that in an emergency situation (i.e. cardiac arrest) intravenous access is the
responsibility of the medical staff.
The insertion of a cannula immediately following a medical review is the responsibility of the
medical staff.
If a Cannula has been in situ for 72 hours, is patent and free from complications, the decision
not to re-site the Cannula must be documented (including rationale) in the patient’s notes
by the decision making Registered Nurse/Midwife or Doctor and reviewed every 8 hours.
Prescription of 0.9% sodium chloride for flushing of the device on insertion and to maintain
patency.
Registered Nurses/Midwives
 Inspection of the insertion site and surrounding tissues for problems when administering
drugs or fluids and to act on findings.
 The decision to cannulate will only take place when there is a specific indication and in a
situation in which they are competent to do so.
 Only the superficial veins of the lower arm and hands should be used for cannulation by
non-medical staff. Cannulation should not be attempted above the elbow joint.
 In the event of a problem arising with the Cannula, it should be removed and re-sited as soon
as possible.
 If a Cannula has been in situ for 72 hours, is patent and free from complications, the decision
not to re-site the Cannula must be documented (including rationale) in the patient’s notes
by the decision making Registered Nurse or Doctor and reviewed every 8 hours.
 Under the ‘ALERT’ (Acute Life Threatening Events Recognition and Treatment) protocol,
registered nurses who have attended the Trust ‘ALERT’ study day within the last 5 years can
insert peripheral cannula in an emergency situation when the need for intravenous access
can be anticipated and/or to initiate emergency treatment if competent to do so.
 On completion of the insertion record the time, date and site of insertion including signature
in the appropriate place in the patients notes/Care and
 Record of Insertion and Removal of Peripheral Intravenous Cannula (Appendix L).
 In order to prevent unnecessary trauma to the patient only two attempts should be made by
each practitioner. A new cannula must be used on each attempt.
 Cannulation should not be performed on patients under the age of 16 unless specifically
trained to do so and have undergone a period of supervised practice in paediatric
cannulation.
Page 9 of 65
Assistant Practitioners, Health Care Assistants (Bands 2 and 3) and Medical Support Workers
Only insert a cannula in the following situations :
 Following the request of a Doctor or Registered Nurse
 Following a request from imaging departments
 Following a VIP Score assessment of 2 or more when a Cannula is still required
o Cannulation should not be performed on patients under the age of 16 unless
specifically trained to do so and have undergone a period of supervised practice in
paediatric cannulation.
o Only the superficial veins of the lower arm and hands should be used for cannulation
by non-medical staff. Cannulation should not be attempted above the elbow joint.
o In the event of a problem arising with the Cannula, it should be removed and re-sited
as soon as possible.
o In order to prevent unnecessary trauma to the patient only two attempts should be
made to each practitioner. A new cannula must be used on each attempt.



Ensure that the 0.9% sodium chloride solution used for the flushing of the device on
insertion is prescribed and checked with a Registered Nurse/Midwife prior to
administration.
Do not attempt to attach or administer any IV fluids or administer drugs via the cannula
after the insertion of the device.
Do not attempt to flush an existing cannula i.e. if an infusion has stopped running.
On completion of the insertion record the time, date and site of insertion including signature in the
appropriate place in the patients notes/Care and Record of Insertion and Removal of Peripheral
Intravenous Cannula (Appendix L)
Record any blood samples obtained in the patients notes.
Staff working in Accident and Emergency
(As above and including the following)
Cannulation should only take place if there is a specific indication.
Cannulae should not be inserted in patients who will be asked to sit in the waiting room, however,
on the rare occasion, this becomes necessary it is the responsibility of the Walk-in Triage nurse to
closely observe and monitor the patient.
4.14 General principles and additional information for peripheral cannulation.
Environment
Ensure that the correct lighting, ventilation, privacy and position of the patient are taken into
consideration.
Any intravascular line which is inserted in suboptimal conditions is at high risk of infection. Normally
a peripheral line e.g. Venflon must be changed every 3 days. If the line is inserted in suboptimal
conditions e.g. by ambulance staff or other emergency, it must be replaced within 24 hours.
All ambulance-inserted lines are being labelled using a red sticky label applied to
Page 10 of 65
the IV dressing. This indicates that the line must be removed within 24 hours.
Sites for peripheral cannulation
The area of choice for cannulation is the forearm. Other common sites are the back of the hand or
occasionally the antecubital fossa. The palm of the hand and the underside of the wrist should be
avoided.
Avoid placing cannula over mobile joints as this can result in an increased risk of mechanical
phlebitis, tissuing and an infusion that intermittently stops.
If hair removal around the insertion site would improve the ability of the fixation device to adhere to
the skin, this must be achieved by trimming the hair using clinically clean scissors or patients own
clippers. Shaving with a razor should not be performed because of the potential for causing microabrasions, which increase the risk of infection. Depilatory creams should not be used because of
the potential for allergic reaction.
Local anaesthetic creams should be considered for use prior to cannulation; they can be of
particular benefit for patients with needle phobias or patients with cognitive problems i.e. dementia,
delirium, learning difficulties. N.B. Local anaesthetic creams must only be applied following a
doctor’s/nurse prescriber’s prescription or patient group direction by a registered nurse/midwife.
Size of Cannula
The size of cannula choice is dependant upon treatment prescribed and the condition of the
patient’s veins. A vein must be able to accommodate the size and length of the cannula.
Cannulation sizes and flow rate are as follows:
Colour
Yellow
Blue
Pink
Green
Grey
Orange
Gauge
24
22
20
18
16
14
Flow Rate
1.5 litres/hr
1.5 litres/hr
3.3 litres/hr
5.4 litres/hr
10.2 litres/hr
15.9 litres/hr
The ideal size of cannula for a blood transfusion is 20g (pink) unless otherwise indicated.
A larger size cannula increases the risk of infection (Ingram P, Lavery I 2007). In general the
smallest gauge of cannula should be selected to prevent damage to the vessel intima and ensure
adequate blood flow around the cannula to reduce the risk of phlebitis (Dougherty 2008).
Blood samples from cannulae
 Blood samples can be obtained from the cannula by attaching the Monovette multi-adaptor to
the cannula before attaching the obturator. Blood bottles are then attached to the multi-adaptor
and samples obtained as per the clinical procedure for venepuncture. Blood samples must be
obtained prior to flushing the cannula with 0.9% sodium chloride. The cannula must then be
flushed on completion of the procedure.
 Blood samples should only be obtained from cannulas at the initial insertion of the device.
 Staff obtaining blood samples for ‘group and save’or‘group and crossmatch’ must referto their
clinical area procedures prior to obtaining blood or seek advice from theTrustTransfusion
Page 11 of 65
Coordinator.
Procedure
Equipment
Intravenous cannula of appropriate size
2% Chlorhexidine and 70% alcohol ampoule Clean tourniquet
Occlusive IV dressing Sterile gloves
Plastic apron
Suitable tray
Sharps bin
Peripheral cannulation pack
10ml syringe and needle.
5mls 0.9% sterile sodium chloride (prescribed on patient’s prescription sheet). Sterile gauze.
Placing a Peripheral intravenous cannula
Action
Identify
need
cannulation.
for
intravenous
Rationale
Avoid unnecessary insertion or changing of
cannula.
Explain the procedure to the patient and
allow time for discussion. (Alternative
formats are available on request e.g.
translation services, sign language
services, induction loop).
To ensure that the patient understands the
procedure and gives his/her valid consent.
Ask the patient if they have had any
problems at previous cannulation
attempts.
To acquaint the nurse fully with the patients’
previous venous history and identify any
changes in the patients’ clinical status that may
influence vein choice, e.g. mastectomy.
If visibly clean wipe plastics sharp tray
with a 70% alcohol wipe. If not visibly
clean wipe with Chlorclean and then
use a 70% alcohol wipe and allow to dry
for about 30 seconds whilst
assembling your equipment.
To ensure the plastic sharps tray is clean and to
minimise the risk of cross infection.
Apply a tourniquet above the site
ensuring the arterial pulse can still be
felt, palpate the site and select a vein.
To engorge vein facilitate ease of selection.
Release tourniquet.
To involve the patient in the treatment and
reduce anxiety.
To differentiate between veins, arteries and
tendons.
To ensure patient does not feel discomfort whilst
cannula is selected and hand washing is taking
place.
Page 12 of 65
Decontaminate hands using soap and
water or use alcohol gel if hands visibly
clean. Put on apron and open
cannulation pack and open all
necessary equipment onto sterile
field.
To reduce the risk of cross-infection.
Re-apply the tourniquet above the
chosen site ensuring the arterial pulse
can still be felt and re-palpate the
chosen vein.
To re-establish the site of the chosen vein.
Put on sterile gloves and clean the
chosen site with the 2% chlorhexidine
and 70% alcohol ampoule. Allow the
skin to dry for 15-30 seconds. After
cleansing do not re-palpate the vein.
To maintain asepsis and minimise risk of
infection, avoid stinging pain on insertion of
needle and avoid re-contaminating a cleansed
site.
Ensure the needle of the cannula is in
the bevel-up position and can be
visualised out of the end of the cannula.
Hold the cannula in one hand (usually
dominant hand), ensuring the needle
does not withdraw up into the cannula
itself.
To avoid damage to the intima of the vein.
Stabilise the selected vein by gently
pulling back on the skin a few
centimetres below the proposed
insertion site with the other hand.
To immobilise the vein to reduce the risk of
movement on needle insertion.
Insert the cannula through the skin into
the vein at an angle of approximately 25
- 35 depending on the depth of the vein.
The cannula will be a few millimetres
into the vein at this point.
This angle reduces the risk of passing the
needle through the vein. To facilitate a pain- free
venepuncture. To avoid damage to the intima of
the vein.
Successful cannulation is confirmed by
free-flow of blood into the flash back
chamber.
This indicates the needle has entered the vein.
Lower the angle of the device until it is
almost flush with the skin. Adjust the
direction of the device to that of the vein
and advance the entire needle and
cannula assembly a further few
millimetres into the vein.
To ensure the entry into the lumen of the vein.
Withdraw the introducer needle very
slightly from the cannula, keeping the
cannula steady. A second flashback of
blood will be seen along the shaft of the
cannula.
To establish the cannula is still in a patent vein
Page 13 of 65
Keeping the needle still, advance the
cannula forward off the needle and into
the vein as far as it will go.
To place the cannula fully into the vein.
Release the tourniquet and place a
finger over the vein distal to the cannula
tip and apply pressure.
Reduce pressure in the vein and to prevent
blood spillage.
Remove the needle and discard
immediately in the sharps bin, then cap
the cannula using an obturator (any
blood samples can be taken at this
point before flushing)or attach a readyprimed intravenous fluid line with fluids
(if prescribed) to the end of the cannula.
(Registered nurses/midwives and
medical staff ONLY to attach IV
fluids)
To reduce the risk of accidental sharps injury
Clean the area surrounding the entry
site if needed and apply a transparent
occlusive dressing (i.e. Tegaderm,
Opsite 3000).
To protect puncture site and prevent entry
of micro-organisms. To prevent movement of
the device this can result in irritation of the vein
wall.
Complete date of inserting of the
cannula on the date strip and apply date
strip to the side of the dressing and not
over the insertion site.
To enable visible inspection of the insertion site
and to establish when the cannula was
inserted.
Using 2-5ml of 0.9% sodium chloride,
slowly flush the cannula via the injection
port (sign for this on the patient’s
prescription sheet) – NOTE- Following
insertion only because after use the port
will no longer be sterile. Subsequent
use of the port should be avoided if
possible. Observe for signs of leakage,
swelling. Ask the patient if any
discomfort is felt. If anyof the above is
present remove the device and replace.
To establish location in vein and the patency of
cannula
If fluids are prescribed, once patency is
established, set correct flow rate in
accordance
with
Trust
policy.
(Registered
Nurses/midwives
and
Medical Staff ONLY).
To ensure correct rate of infusion
To prevent bleeding from the end of the cannula.
To avoid entry of bacteria, this could lead to
infection.
Page 14 of 65
Dispose of clinical waste
Hospital
Waste Disposal Policy No 15.
as
per
To ensure the correct disposal of clinical waste.
To maintain health and safety.
Remove and dispose of gloves in yellow
clinical waste bag.
Decontaminate
hands as per point 9.
To ensure the correct disposal of clinical waste.
To maintain health and safety.
To reduce the risk of cross-infection.
Record date, time and position of
insertion on the Trust approved Visual
Infusion Phlebitis (VIP) chart.
To ensure record is kept of insertion allowing resiting every 72 hours.
Page 15 of 65
4.2 Placement of a subcutaneous needle
4.21 Aim
To ensure that all patients who receive subcutaneous fluids do so in a safe manner by appropriate
qualified and competent staff.
4.22 General principles
This procedure can be undertaken by a Registered Nurse or Midwife who possess the necessary
knowledge and skills for safe practice. Student Nurses/Midwives may also undertake this procedure
under direct supervision by a Registered Nurse/Midwife.
Indications for use
Subcutaneous fluids can be used as an alternative to intravenous fluid replacement in some
circumstances. The use of subcutaneous fluids is a medical decision based on the patient’s general
condition and fluid requirement.
Benefits to the patient
Insertion of the butterfly needle is less distressing to the patient than intravenous lines. Can be set
up and administered by a registered nurse in any care environment.
Gives the patient greater mobility and comfort
Can be sited where a patient cannot easily reach, which is beneficial in confused/agitated patients.
Subcutaneous fluids are unsuitable in the following circumstances:
Severe dehydration, shock or poor tissue perfusion
Fluid requirement of more than 3 litres of fluid in a 24-hour period
Where precise control of volume and rate of infusion is essential (e.g. in some patients with heart
failure or acute renal failure)
Patients with clotting disorders
Infusion sites
Appropriate sites
Healthy, non-irritated/injured skin with adequate amounts of subcutaneous tissue Abdomen area
(avoid upper anterior abdominal wall if PEG is being considered) Anterior chest below the clavicle
area (avoid soft breast tissue)
Lateral aspect of upper arm or thigh
Back, usually below the shoulder blade (useful in confused patients)
Avoid
Oedematous tissue
Lympoedematous tissue, the rate of absorption will be affected. A cannula breaches the skin
integrity thus increasing the risk of infection in skin that is already susceptible
Skin that has recently been irradiated
Rashes
Mastectomy sites
Areas close to a stoma
Lower peripheral limbs
Bony prominences due to lack of subcutaneous tissue
Areas of skin with evidence of infection (e.g. cellulitis or folliculitis)
Procedure
Equipment
Prescription chart
Sharps box/ tray
Butterfly cannula and line (smallest gauge and shortest length of needle available to establish
Page 16 of 65
subcutaneous access)
Standard Intravenous giving set (20 drops = 1ml)
Infusion fluid
Non sterile gloves
Sterile transparent dressing
Hyaluronidase and diluent if required (as prescribed)
Needles and syringe (for reconstitution and administration of Hyaluronidase)
Placement
Placing a Subcutaneous needle
Action
Explain the procedure to the patient
(Alternative formats available on request,
e.g. translation services, sign language
services).
Rationale
To obtain the patient’s consent and cooperation
Check the fluid with prescription chart
To ensure correct type and quantity is
administered
To avoid the introduction of infection
Wash hands and apply non-sterile
gloves.
Using a non-touch technique attach the
giving set to the fluid bag to be infused
and the butterfly cannula and line.
Prime assembled equipment with the
fluid to be infused.
Assess patient for suitable site for
infusion.
Avoiding touching the ends of the
infusion line (that attach to the infusion
bag/cannula to be inserted into the
patient) will help avoid the introduction of
infection.
To prevent introduction of air to the
patient
To provide a comfortable and safe area
for fluid absorption
Clean the infusion site with alcohol swab
and allow to dry.
To avoid introduction of infection.
Grasp the skin firmly and Insert the
primed infusion needle into the skin at
an angle of 45- 60 degrees and release
the skin.
To elevate the subcutaneous tissue.
Shallower positioning less than 45
degrees may shorten the life of the
infusion site.
If blood appears in the line on insertion
of the needle withdraw immediately and
repeat process with a new butterfly
needle
(do
not
re-administer
Hyaluronidase into the same site).
To ensure a blood vessel has not been
punctured.
Affix the infusion wings and part of the
line firmly to the skin using transparent
film dressing.
Transparent dressing allows observation
of the infusion site and maintain the
correct position of the needle
Ensure date of insertion is recorded on
the dressing.
To remind staff of the date of insertion to
enable the infusion to be resited every
72 hours (including changing the giving
set).
Page 17 of 65
Ensure patient is comfortable.
To ensure the infusion is not causing the
patient any discomfort.
Commence infusion at prescribed rate
and record time, date, and signature on
the prescription sheet.
To ensure fluid is administered as
prescribed.
Document the procedure in the patient’s
care plan (including expected date for
resiting the infusion).
Check the site 4 hourly observing for
reddening, oedema, pain at site,
infection/abscess – remove if present,
seek medical advice and document.
To ensure accurate records are kept of
the procedure and ongoing care.
Rotate the site every 72 hours changing
the butterfly needle and giving set and
label with date and time.
In
immunocompromised patients the giving
set should be changed every 24 hours.
To reduce risk of infection.
To ensure fluid is being infused as
prescribed and enable early recognition
of any problems.
Page 18 of 65
4.3 Placement of a Peripherally Inserted Central Catheter (PICC)
Indications for use
PICCs are rapidly becoming an acceptable alternative to traditional central venous catheters and
tunnelled catheters, with advantages of patient comfort, reduced insertion complications, reduced
associated infection rates and ease of placement.
PICCs have the potential to provide continuous venous access for patients throughout the duration
of the treatment episode, avoiding delays in both recovery and discharge from hospital.
Placement of a PICC line should be considered for patients who meet the following criteria




Delivery of Total Parenteral Nutrition (TPN)
Delivery of intravenous therapy anticipated to last greater than four weeks.
Delivery of irritant or vesicant intravenous therapy.
Delivery of multiple simultaneous therapies.
Environment
Patients requiring non urgent PICC lines should have these placed in designated areas in the trust. There are
designated rooms on Satchi suite, Radiology and the Lilac centre. Urgent PICC lines can be placed in the
ward environment as long as maximal aseptic precautions are adhered to.
4.31 Education and Supervision
1. All staff new to the skill of Peripherally Inserted Central Catheter Placement must attend a
formal Peripherally Inserted Central Catheter Placement Workshop.
2. Complete a minimum of 10 successful supervisions of practice.
3. Complete the ‘Peripherally Inserted Central Catheter Placement competency sheet.
4. Demonstrate the necessary knowledge and skills to practice unsupervised.
4.32 Supervisors Responsibilities
 Supervisors must be either a registered nurse/midwife or doctor competent in
Peripherally Inserted Central Catheter Placement.
 Supervisors must directly supervise the practitioner when they perform PICC placement
until they have been assessed as competent to practice without direct supervision.
 Competence to practice without direct supervision is only achieved following a minimum
of 10 competent successful placements.
 Supervisors must complete and sign the record of supervision following each PICC
placement attempt.
 Supervisors must document any recommendations for further supervised practice and/or
repeating the PICC placement workshop on the record of supervision form. The rationale
for the recommendations must be included.
 The final supervised practice session should be under the supervision a designated
practitioner skilled in PICC Placement.
N.B. Competence in the procedure is described as placement of the device without the intervention
of the supervisor at any point during the process.
Any practitioner competent PICC placement can provide supervised practice; however, it must be
the Senior practitioner who is skilled in PICC placement the FIRST and LAST PICC placement .
Page 19 of 65
This is to ensure continuity of the learning experience. It must be the designated senior practitioner
who signs off the Competency Assessment Framework form. (APPENDIX J)
4.33 Equipment

2% chlorhexidine gluconate/70% isopropyl alcohol (3mls) X 2 NB. If the patient has a known
allergy to chlorhexidine gluconate, then povidone iodine 10% should be used
alternatively.
 Clean Tourniquet. (Disposable if the patient is being barrier nursed)
 PICC placement pack
Contents Include:- 1 x Outer wrap
- 1 x Large blue tray 30 x 20 x 5cm
- 1 x 5ml Luer slip syringe
- 1 x 10ml Luer lock syringe
- 1 x 20ml Luer lock syringe
- 1 x Hypodermic needle 23g x 1” (25mm)
- 1 x Drawing up needle 18g x 1.5” (40mm)
- 20 x Swabs 10 x 10 cm – 4 ply. White. Non woven
- 2 x Hand towels
- 3 x Gallipots 60ml
- 2 x Sponge sticks
- 1 x Semi-permeable dressing 10 x 14 cm
- 1 x Black silk suture 2.0 with 39mm with straight needle
- 1 x Metal curved forceps
- 1 x Metal scissors
- 1 x CDC Maximum barrier fenestrated drape 140 x 100cm
- 1 x Examination gown
 Sterile gloves.
 Sharps Bin.
 Absorbent pad
 Stainless steel trolley
 PICC Line. (4fr-Single Lumen or 5fr-Dual Lumen)
 250ml Sodium Chloride 0.9%
 Tetracaine 4%. 1.5g tube
 Clinical waste bag
 Tape measure
 Ultrasound Machine
If inserting under ultrasound guidance (you will also need)
 1% Lidocaine Local Anaesthetic (Instead of Tetracaine 4%)
 Sterile Ultrasound Sheath
 Sterile Aquasonic Gel x 2 sachets
 Universal Micro introducer Kit
Contents include:- 1 x Introducer, Peel apart.
- 1 x Guidewire, Stainless steel
- 1 x Needle Introducer
- 1 x IV Catheter
- 1 x Scalpel
Page 20 of 65
N.B. This procedure requires an assistant to maintain asepsis.
Procedure
Placing a Peripherally Inserted Central Catheter
Action
Rationale
Check patient identity.
To ensure correct patient
Consult patients medical notes
Explain the procedure to the patient
and allow time for discussion.
To confirm reason for PICC placement.
To become familiar with patients medical
history.
To check for any contra indications for PICC
placement.
To ensure that the patient understands the
procedure obtaining informed consent.
To involve the patient in the treatment and
reduce anxiety.
Cannula over needle insertion
Apply a tourniquet above the
antecubital fossa, assess each arm
individually, ensuring the arterial
pulse can still be felt, palpate the
site and select a vein.
or
Ultrasound guided insertion
Apply ultrasound gel to area to be
visualised.
Visualise the veins and arteries
using ultrasound.
Select appropriate vein.
Release tourniquet.
To engorge the vein and
selection.
Record a baseline set of
Physiological observations. BP,
Pulse, Respiratory Rate, oxygen
saturations.
To ensure patient is haemodynamically stable
prior to procedure, and to enable staff to identify
a change in patients condition post procedure.
Cannula over needle insertion
Apply Tetracaine 4% Local
anaesthetic to selected site and
cover with film dressing.
To minimise pain on insertion.
When the Tetracaine 4% Local
anaesthetic gel has been on for
approximately 1 hour, position the
patient comfortably on the bed and
facilitate ease of
To differentiate between veins, arteries and
tendons.
To ensure patient does not feel discomfort whilst
preparation for procedure is taking place.
To ensure gel is contained within selected area
To ensure
comfort and maintain patients
Page 21 of 65
remove the gel.
Ensure the screens are drawn and
doors are shut.
privacy.
Assistant to clean stainless steel
trolley with Chlorclean and then
bring trolley to the patients bedside.
To prevent contamination of sterile field and
maintain asepsis, and in preparation to begin
procedure.
Extend the patients arm 90 degrees
to their body and measure the
distance from the level of the ante
cubital fossa then down to the third
intercostal space.
To give the approximate length of catheter to be
inserted.
Elevate the head of the bed 15 to 30
degrees.
Place the cannulation site below the
level of the heart.
To enhance vasodilation, Catheter insertion is
facilitated when there is adequate vasodilation
of the vessel intended for cannulation.
Place absorbent pad under the
selected arm.
To absorb any spillages.
Position tourniquet loosely on
selected arm ready to tighten
In preparation to facilitate access in procedure.
Wash hands using Ayliffe technique,
which aims to cover all surfaces of
the hands and cuffs. The use of
liquid soap followed by alcohol gel
(in accordance with hospital policy)
is required. Hands should be rinsed
in warm running water before and
after applying the hand wash agent.
To comply with EPIC guidelines on hand
hygiene and reduce the risk of cross infection.
Assistant to clean stainless steel
trolley with Chlorclean and open
insertion pack onto trolley using drop
technique.
To prevent contamination of sterile field and
maintain asepsis.
Open up insertion pack and dry
hands with sterile towels.
To reduce the risk of cross infection.
Put on sterile gown and apply well
fitting sterile gloves.
To maintain sterile environment and comply with
EPIC guidelines.
Arrange sterile supplies, asking
assistant to open packages onto
sterile field using drop technique.
To prevent contamination of sterile field and
maintain asepsis.
Assistant to peel open packaging of
Sodium Chloride 0.9% 250ml to
To prevent contamination of sterile field and
maintain asepsis.
Page 22 of 65
enable inserter to retrieve sterile
contents and place on sterile field.
Assistant to open PICC line pack
onto sterile field using drop
technique.
To prevent contamination of sterile field and
maintain asepsis.
Remove PICC line from its sterile
pack and examine it along its entire
length.
Place the catheter in the large blue
tray. Irrigate the catheter directly
priming with the sodium chloride
0.9% in the tray using 20ml luer lock
syringe. Using positive and negative
pressure
by
flushing
and
withdrawing with sodium chloride
0.9%
Clean the chosen site with. 2%
chlorhexidine gluconate/70%
isopropyl alcohol using repeated up
and down, back and forth strokes.
Allow the skin to dry for 30 seconds.
NB. If the patient has a known
allergy to chlorhexidine
gluconate, then povidone iodine
10% should be used alternatively.
To check the line for any damage/leaks. During
storage of the line the latex valve can become
compromised.
Flushing ascertains whether the line is patent.
To maintain asepsis and minimise risk of
infection, avoid stinging pain on insertion of
needle and avoid re-contaminating a cleansed
site.
To comply with EPIC guidelines.
Page 23 of 65
Place maximum barrier fenestrated
drape over top of patients arm.
To create a sterile field.
Assistant to tighten tourniquet
without compromising sterile field.
To engorge the veins and facilitate ease of
selection.
To prevent contamination of sterile field and
maintain asepsis.
Cannula over needle technique follow 24 - 30
Palpate the vein. Remove the
To identify the vein in preparation for
needle guard and perform
cannulation.
cannulation.
Slowly insert the introducer
cannula/needle assembly into the
vessel at a shallow angle (15 to 30
degrees), using standard technique.
This angle reduces the risk of passing the
needle through the vein and to avoid damage to
the intima of the vein.
Observe for a blood flow return into
the flashback chamber. Holding the
needle stationary, advance the
sheath into the vessel
To indicate the needle has entered the vein
Assistant to release tourniquet
without compromising the sterile
field.
Allows passage of the PICC line along the
vessel
Remove the needle from the
cannula and discard in sharps box,
leaving the cannula in place
To reduce the risk of accidental sharps injury.
Maintain stability of the cannula and
advance it, if it passes easily. Apply
slight pressure above the insertion
site to minimise blood flow. Observe
pattern of blood flow from the
vessel.
To ascertain a vein, not an artery, has been
cannulated. The pulsating flow of blood is a
reliable indicator of arterial access. If arterial
access is suspected remove introducer and
apply direct pressure to site immediately.
Page 24 of 65
Thread the PICC line into the vein
Rapid entry may cause venospasm.
through the cannula to the depth
determined by previous
measurements advancing the
catheter slowly.
Ultrasound guided technique follow 31-43
Draw up Lidocaine 1% using 5ml
In preparation for administration
syringe and drawing up needle.
Visualising the vein, infiltrate 1%
Lidocaine in the surrounding area
(withdraw then inject), ensuring it is
not injected into the vein.
To avoid accidental intravascular injection.
Release the tourniquet and allow
Lidocaine to take affect.
To return blood flow to the arm and ensure
patient does not feel any discomfort.
Observe the pattern of blood flow
from the vessel.
To ascertain a vein, not an artery, has been
cannulated. The pulsating flow of blood is a
reliable indicator of arterial access. If arterial
access is suspected remove introducer and
apply direct pressure to site immediately.
To gain access to the vein with view of needle tip
piercing wall of vein.
Visualising the vein with the
ultrasound probe, advance the
needle into the vein continually
visualising this on the screen.
Observe for the white appearance
of the needle pushing against the
wall, ‘tenting’ of the vein. Advance
needle into vein.
Insert the flexible end of the guide
wire into the needle introducer.
Advance the guide wire 5 to 10 cm
into the vein.
To gain access to the vein with the guide wire to
allow access for the introducer.
Gently withdraw and remove the
introducer needle, holding the guide
wire in position.
To maintain guide wire patency in the vein.
Make small incision to either side of
the guide wire at the point of entry
into the skin.
To aid introduction of dilator.
Thread the peel-apart sheath
introducer over the guide wire, when
in place remove the guide wire.
To allow for insertion of the sheath.
Page 25 of 65
Remove the introducer stylet from
the peel away sheath, leaving the
peel way sheath in position.
To allow for correct positioning of the sheath in
preparation for introduction of PICC line.
Continue to advance the catheter.
For central placement, when the tip
has advanced to the shoulder (15 to
20cms) the patient should turn head
(chin to shoulder) towards the
insertion site.
To close off entry to the jugular vein and
prevention of entry by the PICC tip into the
jugular vein.
Complete catheter advancement to
the lower 1/3 of the superior vena
cava using measurements taken
from the level of the ante cubital
fossa.
To ensure correct position of tip.
If Dual Lumen Bard PICC Line or ultrasound guided Follow points 44 - 45
Withdraw the cannula from the vein
To allow for application of suture wing and
and away from the insertion, pull the
securing of line.
two splitting handles away from each
other to allow the cannula to be split
and discarded.
Remove the pre placed guide wire from
the catheter.
Remove the suture wing from the
delivery card. Squeeze the suture
wing together so that it splits open.
Place the suture wing around the
catheter, near the insertion site.
Secure with steristrips or sutures.
To secure the device and to minimise the risk of
catheter breakage and embolisation.
Page 26 of 65
If Single Lumen Bard PICC Line Follow points 46 - 48
Slide the intact cannula off the end
To allow for fixation of the extension leg onto the
of the PICC line.
PICC.
Trim the end of the catheter to the
required length with the sterile
scissors.
To remove excess length and to maintain
sterility of the PICC.
Slide the over-sleeve portion of the
end connector and the winged
portion of the end connector
together, aligning the grooves of the
connector with the barbs on the
winged portion of the connector
To ensure correct alignment of the connector
barbs and grooves of extension leg.
Advance completely until the
connector barbs are fully attached. A
locking sensation will confirm that
the two pieces are fully engaged.
To ensure correct fitting of the connector barbs
and grooves of the extension leg.
Using the 20ml syringe, fill with
10mL of 0.9% Sodium Chloride.
Attempt to aspirate blood from each
of the lumens. If blood is aspirated,
flush the line using a pulsatile
(push/pause) technique
Apply injection cap.
To check and maintain patency of PICC Line.
Secure the line using the Statlock
device.
To prevent backflow of blood from the PICC line
and ensure a closed circuit to prevent
contamination of the line.
To prevent movement and dislodgement of the
PICC line by providing extra stability of the line.
Place a folded piece of gauze over
the insertion site for the first 24
hours post insertion.
Place transparent occlusive semipermeable dressing over the
insertion site.
To absorb any post insertion bleeding.
Dispose of sharps safely into a
sharps box.
To reduce the risk of accidental sharps injury.
Dispose of clinical waste as per
Hospital Waste Disposal Policy No.
15
To ensure the correct disposal of clinical waste.
To maintain health and safety. To reduce the
risk of cross infection.
Remove and dispose of gloves in
yellow clinical waste bag.
Decontaminate hands as per point
13.
To ensure the correct disposal of clinical waste.
To maintain health and safety. To reduce the
risk of cross infection.
To keep the insertion site clean and dry
Page 27 of 65
Document the procedure in the
patients case notes.
To meet legal and NMC requirements.
Request patient chest x-ray.
To confirm that tip of PICC line is resting in the
lower 1/3 of the superior vena cava prior to use.
Page 28 of 65
4.4 Placement of Central Venous Catheter (CVC)
4.41 Indications for use
CVCs have the potential to provide continuous venous access for patients throughout the duration
of the treatment episode, also as a method of monitoring fluid balance status in specialist areas.
CVCs are considered a short term solution for patients who have become acutely unwell.
Placement of a CVC line should be considered for patients who meet the following criteria



Delivery of Total Parenteral Nutrition (TPN)
Delivery of irritant or vesicant intravenous therapy.
Delivery of multiple simultaneous therapies.
Environment
CVCs are traditionally placed in acute environments, such as the Intensive Care Unit, Coronary Care Unit,
Emergency department Resuscitation and Theatre Anasesthetic rooms. Placement of any vascular
access device (VAD), particularly central vascular access devices, is a strict aseptic procedure
which should only be undertaken by medical staff and registered nurses that have had the
appropriate training and supervision and have been deemed competent.
Equipment
Clean trolley to prepare sterile area
Appropriate central vascular access device (see table below)
Central line kit (where available, includes the following)
 Sterile towels x 3
 Cut down set
 Sterile large bowl
 Sterile surgeons gown
 Sterile surgeons gloves
 20 ml syringe
 10ml syringe
 5ml syringe
 Green needle
 Blue needle
 Sterile gauze swabs x 4
 Silk suture
 Transparent semi-permeable dressings x 2
 Sterile gel
 Sterile sheath
 Mask and theatre cap
Ametop gel
Lidocaine 1%
500ml or 250 ml 0.9% normal saline
Chlorhexidine 2 % in 70% alcohol (Chloraprep skin preparation) or single patient use povidoneiodine solution if patient has sensitivity to chlorhexidine.
Page 29 of 65
4.41 Procedure
N.B. This procedure requires an assistant to maintain asepsis.
Action
Check patient identity.
Placing a Central Venous Catheter
Rationale
To ensure correct patient.
Consult patients medical notes
To confirm reason for CVC placement.
To become familiar with patients medical history.
To check for any contra indications for CVC
placement.
Explain the procedure to the patient
and allow time for discussion.
To ensure that the patient understands the
procedure obtaining informed consent.
To involve the patient in the treatment and
reduce anxiety.
Record a baseline set of
Physiological observations. BP,
Pulse, Respiratory Rate, oxygen
saturations.
Place patient supine or
Trendelenburg positions.
To ensure patient is haemodynamically stable
prior to procedure, and to enable staff to identify
a change in patients condition post procedure.
Apply ultrasound gel to area to be
visualised.
To differentiate between veins, arteries and
tendons.
To engorge the vein and
selection
facilitate ease of
Visualise the veins and arteries
using ultrasound.
Select appropriate vein
Place absorbent pad under the
selected area
To absorb any spillages.
Wash hands using Ayliffe
technique, which aims to cover all
surfaces of the hands and cuffs.
The use of liquid soap followed by
alcohol gel (in accordance with
hospital policy) is required. Hands
should be rinsed in warm running
water before and after applying the
hand wash agent.
To comply with EPIC guidelines on hand
hygiene and reduce the risk of cross infection.
Assistant to clean stainless steel
To prevent contamination of sterile field and
Page 30 of 65
trolley with Chlorclean and open
insertion pack onto trolley using
drop technique.
maintain asepsis.
Open up insertion pack and dry
hands with sterile towels.
To reduce the risk of cross infection.
Put on sterile gown and apply well
fitting sterile gloves.
To maintain sterile environment and comply with
EPIC guidelines.
Arrange sterile supplies, asking
assistant to open packages onto
sterile field using drop technique.
To prevent contamination of sterile field and
maintain asepsis.
Assistant to peel open packaging of
Sodium Chloride 0.9% 250ml to
enable inserter to retrieve sterile
contents and place on sterile field.
To prevent contamination of sterile field and
maintain asepsis.
Assistant to open CVC line pack
onto sterile field using drop
technique.
To prevent contamination of sterile field and
maintain asepsis.
Remove CVC line from its sterile
pack and examine it along its entire
length.
Place the catheter in the large blue
tray. Irrigate the catheter directly
priming with the sodium chloride
0.9% in the tray using 20ml luer
lock syringe. Using positive and
negative pressure by flushing and
withdrawing with sodium chloride
0.9%
To check the line for any damage/leaks. During
storage of the line the latex valve can become
compromised.
Flushing ascertains whether the line is patent.
Clean the chosen site with. 2%
chlorhexidine gluconate/70%
isopropyl alcohol using repeated up
and down, back and forth strokes.
Allow the skin to dry for 30 seconds.
NB. If the patient has a known
Allergy
to
chlorhexidine
gluconate, then povidone iodine
10% should be used alternatively.
To maintain asepsis and minimise risk of
infection, avoid stinging pain on insertion of
needle and avoid re-contaminating a cleansed
site.
To comply with EPIC guidelines.
Place maximum barrier fenestrated
drape over top of area.
To create a sterile field.
Draw up Lidocaine 1% using 5ml
syringe and drawing up needle.
In preparation for administration
Page 31 of 65
Visualising the vein, infiltrate 1%
Lidocaine in the surrounding area
(withdraw then inject), ensuring it is
not injected into the vein.
To avoid accidental intravascular injection.
Observe the pattern of blood flow
from the vessel.
To ascertain a vein, not an artery, has been
cannulated. The pulsating flow of blood is a
reliable indicator of arterial access. If arterial
access is suspected remove introducer and
apply direct pressure to site immediately.
Visualising the vein with the
ultrasound probe, advance the
needle into the vein continually
visualising this on the screen.
Observe for the white appearance
of the needle pushing against the
wall, ‘tenting’ of the vein. Advance
needle into vein.
To gain access to the vein with view of needle
tip piercing wall of vein.
Insert the flexible end of the guide
wire into the needle introducer.
Advance the guide wire 5 to 10 cm
into the vein.
To gain access to the vein with the guide wire to
allow access for the introducer.
Gently withdraw and remove the
introducer needle, holding the guide
wire in position.
To maintain guide wire patency in the vein.
Make small incision to either side of
the guide wire at the point of entry
into the skin.
To aid introduction of dilator.
Thread the dilator over the guide
wire and dilate the vessel.
To allow for insertion of the catheter.
Advance the catheter to appropriate
length for ideal central placement.
(i.e. right internal jugular = 15 cm.
left internal jugular = 20 cm).
To assist ideal placement.
Page 32 of 65
Using the 20ml syringe, fill with
10mL of 0.9% Sodium Chloride.
Attempt to aspirate blood from each
of the lumens. If blood is aspirated,
flush the line using a pulsatile
(push/pause) technique
To check and maintain patency of CVC Line
Apply injection caps.
To prevent backflow of blood from the CVC line
and ensure a closed circuit to prevent
contamination of the line.
Secure the line using the Clamp
device and suture to the skin.
To prevent movement and dislodgement of the
CVC line by providing extra stability of the line.
Place a folded piece of gauze over
the insertion site for the first 24
hours post insertion.
Place transparent occlusive semipermeable dressing over the
insertion site.
To absorb any post insertion bleeding.
Dispose of sharps safely into a
sharps box.
To reduce the risk of accidental sharps injury.
Dispose of clinical waste as per
Hospital Waste Disposal Policy No.
15
To ensure the correct disposal of clinical waste.
To maintain health and safety. To reduce the
risk of cross infection.
Remove and dispose of gloves in
yellow clinical waste bag.
Decontaminate hands as per point
13.
Document the procedure in the
patients case notes.
To ensure the correct disposal of clinical waste.
To maintain health and safety. To reduce the
risk of cross infection.
Request patient chest x-ray.
To confirm that tip of CVC line is resting in the
lower 1/3 of the superior vena cava prior to use.
To keep the insertion site clean and dry.
To meet legal and NMC requirements
Page 33 of 65
5. Management of indwelling devices
5.1 General principles for the maintenance and management of vascular access devices.
Aseptic Non-Touch Technique (ANTT)
The principles of ANTT must be adopted when accessing indwelling catheters. Aseptic non-touch
technique is a method used to prevent contamination of susceptible sites by micro-organisms that
could cause infection, achieved by ensuring that only sterile equipment and fluids are used and the
parts of components that should remain sterile, e.g. the tip of intravenous connectors, syringe tips
etc are not touched or allowed to come into contact with non-sterile surfaces (www.antt.co.uk).
Hand washing using the Ayliffe technique, before and after procedures is mandatory.
An indwelling device should be accessed as infrequently as possible and aseptic technique should
always be observed when accessing it. Hubs should be thoroughly cleaned with 2% Chlorhexidine
in 70% alcohol wipes when accessing, and obturators replaced with sterile ones after each episode.
Where possible needle free devices instead of obturators, can be used to reduce the frequency of
openly accessing the catheter.
Needle free devices
Needle free devices connect directly to the end of the line to allow the application of syringes
(without needles) whilst maintaining a closed system via a one way valve.
When the device is activated by an IV device with a male luer fitting, such as a syringe (without a
needle) or an administration set, the fluid pathway is opened to allow the administration of fluids or
aspiration of blood for sampling. Upon removal of the device, the top/septum should automatically
return to its closed/home position and seal the fluid pathway.
Prior to accessing and following the use of the device, ensure that the top/septum of the connector
is in its closed/home position.
There have been reports of the top of the device remaining recessed following use. Swabbing of the
connection in this condition may lead to inadequate decontamination a and a risk of infection
Contributory factors include: application of a downstream clamp to an IV line during a positive
pressure technique (to maintain catheter patency) may result in a recessed septum in some brands
due to the negative pressure generated between it and the closed clamp. When the clamp is
removed, the top should return to its close/home position. Manufacturer’s instructions should be
followed on the application of clamps.
If the top remains recessed after following manufacturer’s instructions the needle free device
must be replaced and the incident reported to purchasing and supplies and reported via
Datix. This will then be reported to the Medicines and Healthcare Products Regulatory Agency.
Intravenous giving sets
 Infusion lines should be labeled and changed every 72hrs (for IV fluids and drugs).
 Blood products every 12 hrs.
 Total parental nutrition (TPN) every 24 hrs or the on the completion of each infusion whichever
is sooner.
Page 34 of 65
If the giving set is disconnected from the central line for any reason it must be discarded.
Observation
All insertion sites should be inspected for signs of infection (erythema, pain, inflammation, oedema
and exudate) every time the device is accessed or at least daily if the device is not being used. VIP
scoring is an objective method of doing this.
Lines delivering medications connected to a CVAD should be inspected for potential air embolism,
contamination or disconnection.
5.2 Indwell times for peripheral cannulae
In accordance with the manufacturers instructions cannulae should be:
Removed or replaced after 72 hours.
The exception to this is if a patient has poor intravenous access.
If a Cannula has been in situ for 72 hours, is patent and free from complications, the decision not to
re-site the Cannula must be documented (including rationale) in the patient’s notes by the decision
making Registered Nurse or Doctor and reviewed every 8 hours.
5.3 General rules of peripheral cannula care
1. The position, time and date of insertion and removal of the cannula must be recorded in the
patients records/Care and Record of Insertion and Removal of Peripheral Intravenous Cannula.
2. The site must be checked every 8 hours using the Visual Infusion Phlebitis score (VIP) for signs
of pain, tenderness, generalised redness of the area or tracking (redness along the line of the
vein), heat, swelling or exudate. Document results and actions taken in nursing and patient case
notes as appropriate.
3. Wash hands; apply gloves and apron before all contact with cannula.
4. Disinfect the access port with a 2% chlorhexidine and 70% alcohol device wipe and allow drying
before use.
5. The site and device must be checked for patency before each use as per point 2. If patent,
slowly flush as above before and after administration of each individual drug, ensuring the drugs
are compatible with 0.9% sodium chloride (registered nurses/midwives, or medical staff only).
6. If not being used consider whether the device is still required, and remove if not. If the device is
to remain in situ it must also be flushed with 2-5 mls of 0.9% sodium chloride using a 10 ml
syringe every 8 hours (Registered Nurses/Midwives or Doctors only) observing the patient for
pain/discomfort or swelling.
7. The device should be properly fixed to the skin using an occlusive dressing to avoid movement
of the device in the vein. Dressings should only be changed if wet, soiled or appear to be loose.
If the dressing is intact, redressing of the device is unnecessary. Re-dressing is an aseptic
procedure. Ideally bandages should not be used to cover peripheral cannula; however
exceptions may include paediatric patients, neonates and patients who are likely to dislodge the
cannula i.e. confused patients. If a bandage has been used it should be removed each time the
site is inspected. Avoid application of additional tape as again this can obscure the site.
8. Carefully handling of the device is essential to avoid contamination of the equipment.
Manipulations should be kept to a minimum to avoid introduction of infection.
9. All connections should be checked for tightness as leakage of fluid can encourage bacterial
formation.
10. Inform the patient to report any signs or symptoms of infection/discomfort to the nursing staff
wherever possible.
Page 35 of 65
5.4 General rules of subcutaneous needle care (Hypodermoclysis)
Management of the infusion site
The site of the infusion should be checked every 4 hours for
 Pain at the administration site
 The site is red and/or inflamed
 The skin is white and/or hard
 Blood is present in the administration set or winged infusion device.
Rotate the insertion site a minimum of every 72 hours or more frequently if the patient
complains of any of the above.
When the site is changed or the infusion becomes dislodged or pulled out a new butterfly
cannula, giving set, and bag of infusion fluid must be used to re-site the infusion.
The giving set must be changed every 24 in the in the immunocompromised patient.
Fluid type and method of administration
Solutions for subcutaneous administration should be isotonic with extracellular fluid. Fluids usually
chosen for subcutaneous administration include:
Sodium Chloride 0.9% (preferred) Sodium Chloride 0.18% and Glucose 4% Sodium Chloride
0.45% in 2.5% Glucose
The following can be given with caution
 Glucose 5%
 Potassium solutions with less than 34 mmol/L of Potassium
Glucose
Infusions of glucose may be at more at risk of causing irritation and inflammation because of the pH
balance of the solution. No more than two litres should be given in 24 hour period and rate of
administration must not exceed 2ml/min (1 litre over 8 hours).
Rapid subcutaneous infusion of electrolyte free solutions can lead to hypotension and
shock.
Potassium
Ulceration can occur following subcutaneous infusions of potassium therefore extra vigilance is
needed at the administration site.
No other fluid type should be given subcutaneously (or medications or electrolytes added to
the solution) without consultation with a pharmacist (other than Hyaluronidase which is added
to the site or the line not the infusate see below).
(For subcutaneous administration of drugs see- Procedure for the intra-muscular and sub-cutaneous
injection of drugs (adults) (2007), Policy and procedure for the use of continuous subcutaneous
infusions (CSCI) in adult palliative care (2007)).
Method of administration
Subcutaneous fluids should be administered via gravity using a standard administration set (20
drops = 1ml). The administration of subcutaneous fluids relies on the permeability of the
subcutaneous tissues to gravity fed fluids therefore the recommendation is subcutaneous fluids
Page 36 of 65
should never be given via an infusion pump.
Rate of administration
Normally, 500ml of fluid is given over eight hours (1ml/min), up to a maximum (usually) of 2 litres
over a 24 hour period. Up to 3 litres can be given in total over a 24 our period but no more than 2
litres can be administered at one site in any one 24 hour period.
Absorption of subcutaneous fluids
Hyaluronidase is an enzyme that can be given to enhance the absorption and diffusion of the
infused solution in the tissues, although no clear benefit to its use has been demonstrated
(Dougherty and Lister 2008).
Hyaluronidase can be considered in the following circumstances;
If more than 2 litres are to be infused over a 24 hour period
When the required infusion rate is more than 2ml/min (1 litre over 8 hours) If swelling around the
infusion site is causing the patient or staff concern.
Hyaluronidase 1500 units dissolved in 1 ml of water for injections or 0.9% sodium chloride should
be injected into the site by subcutaneous injection before the infusion is set up, or injected into the
tubing of the infusion set, about 2cm back from the needle, at the start of the infusion.
http://emc.medicines.org.uk/ It is not recommended that Hyaluronidase is injected into the bag
of infusion solution.
It is recommended that this dose can be given once every 24 hours if required.
5.5 General rules of Central line care
5.6 Changing the Dressing on a Central Vascular Access Device Site
Principles
This guideline applies to all central venous access devices. Care must be taken to avoid
dislodgement of the line during the procedure: attached infusion lines should be disconnected,
where appropriate, to avoid applying traction when the old dressing is removed. Additional securing
methods, such as adhesive dressings or sutures, should be reviewed each time this procedure is
undertaken.
Type of Dressing
Preferably a sterile, transparent, semi permeable dressing should be used to cover the insertion
site. Transparent dressings must be changed every 7 days or sooner if they are no longer intact or
moisture collects under the dressing.
If a patient has profuse perspiration or if the insertion site is bleeding or oozing, a sterile gauze
dressing is preferable to a transparent, semi permeable dressing alone. The application of Cavilon
barrier film (sterile preparation via single use applicator) can assist in the adherence of transparent
dressings to the skin if the patient is sweating profusely.
The need for a gauze dressing should be assessed and changed daily. Gauze dressings must also
be changed if additional inspection of the insertion site is necessary or when the or when the
dressing becomes loosened or soiled.
If the site is oozing, a transparent dressing can be used to cover the gauze, but this should be
treated as with other gauze dressings and changed every 24 hours if they are no longer intact or
Page 37 of 65
moisture collects under the dressing. All dressing changes must be documented in the patient
record.
Dressings on tunnelled or implanted insertion sites (such as Hickman lines) should be replaced
every 7 days until the insertion site has healed, unless there is an indication to change them sooner.
Note: All Broviac skin tunneled lines should be referred to the Medical Emergency nursing
team (Bleep 7154 or ext. 2409 answer phone).
Procedure
Equipment
1. Clean trolley or surface to prepare sterile area.
2. Apron
3. Sterile dressing pack with gloves, gauze and small sterile sheet/towel.
4. Chlorhexidine (2%) with 70% alcohol cleansing preparation
5. Alcohol based hand rub.
6. Non-sterile gloves.
7. Transparent semi-permeable dressing.
8. Sterile gauze
9. Bacteriological swab (if signs of infection)
Changing the dressing on a Vascular Access Device Site
Action
Rationale
Explain and discuss the procedure with the patient.
To ensure that the patient
understands and gives his/her
consent
Screen bed and position patient into a supine position (not
To allow dust and organisms to settle
necessary with peripheral access device).
before preparing sterile field.
To help prevent air embolus.
Wash hands. Using aseptic technique open dressing pack. To prepare for procedure while
Arrange yellow bag in convenient position, but away from maintaining a sterile field. Prevent
sterile area. Again using sterile technique open cleansing contamination of the sterile field.
agent and new dressing and place on open dressing pack
Apply non-sterile gloves. Loosen and carefully remove the To observe and prepare for area for
dressing while supporting the device.
cleaning.
Maintaining position of the device and
prevent it from being dislodged
Dispose of dressing and gloves in yellow bag. Wash Decontamination of hands to prevent
hands/apply alcohol gel.
cross infection.
Inspect the site for signs of infection.
To identify signs of infection.
Page 38 of 65
Apply sterile gloves and take swab for microbiology if any sign To identify specific bacteria.
of infection.
Clean the area using chlorhexidine (2%) solution with 70% To provide optimal condition for
alcohol wipe, allow to dry for 20 seconds then cover with dressing to adhere.
transparent semi-permeable dressing or sterile gauze if site
oozing or patient is sweating profusely (covered with
transparent dressing if required).
Ensure all clinical waste in yellow bag and disposed of To prevent environmental
appropriately.
contamination.
Wash hands on removal of gloves.
Comply with hand washing
guidelines.
Ensure patient is made comfortable.
Document dressing change and any swabs taken in the To maintain accurate records.
health care records/patient care plan.
5.7 Flushing Vascular Access Devices.
Principles
This guideline applies to all central access devices. There are variations between methods of
flushing and solutions used with different types of catheter. The table below illustrates the
differences.
The pulsatile (push/pause) method should be administered in 1ml boluses until all solution is
used; this method creates turbulence to clear the line. All lines should be flushed with 0.9% sodium
chloride using a pulsated push-pause technique
The positive pressure technique requires the operator to clamp the line whilst
administering the last 0.5 ml of solution, so there is a positive pressure in the line and blood does
not return into the catheter at the end of injection. This method is used to complete the final flush
with open ended lines; this technique is not required with valved lines as they do not require clamps
on the line to prevent back flow.
Maintaining patency – types of flushing solutions
There is some evidence to support the use of heparin solution to maintain patency and reduce
bacterial colonisation in open-ended central vascular access devices (CVAD) but this evidence is
not robust. Current recommendations advise that when routinely using catheters they should be
flushed with 0.9% sodium chloride solution.
When used in-frequently and as advised by the manufacturer low dose heparinised saline
should be used (5mls of Heparin Sodium 50units/5ml (Hepsal) as the final flush at the end of the
final administration.
Catheter
Flush solution
Flush Method
Page 39 of 65
Valved PICC
(Bard)
0.9% Sodium chloride injection
(10mls) in 20 ml luer lock syringe
Pulsatile (push/pause) flush technique
with 20ml luer lock syringe.
Non-valved
PICC
lines (Vygon)
0.9% Sodium chloride injection
(5ml) in 10 ml syringe
Pulsatile (push/pause) flush method.
Complete final flush with positive
pressure technique.
Midline
catheters
Bard
(groshongvalve)
Non-tunnelled
central
catheters
0.9% Sodium chloride injection
(5ml) in 10 ml syringe
Pulsatile (push/pause) flush technique
with 10ml syringe.
0.9% Sodium chloride injection
(5ml) in 10 ml syringe
Pulsatile (push/pause) flush method.
Complete final flush with positive
pressure technique.
Skin-tunnelled
catheters
(Hickman)
First with 10 mls of 0.9% Sodium
Chloride injection. Then final flush
with 5mls of Heparin Sodium 50
units/5ml (Hepsal)
Pulsatile (push/pause) flush method.
Complete final flush
with positive pressure technique.
Flushing solutions and methods
All lumens of CVADs should be flushed before and after each use or when not in use once weekly.
All flushing solutions must only be administered following a prescription.
Procedure
Equipment.
1. Clean tray
2. Non-sterile gloves (Sterile gloves if required)
3. Apron
4. Chlorhexidine (2%) in 70% alcohol wipe
5. Alcohol based hand rub.
6. Sterile obturators/caps/needle free system.
7. 10ml syringe.
8. Prescribed 0.9%Sodium chloride injection (and Heparin Sodium (50units/5ml) if required).
Flushing a Vascular Access Device
Action
Rationale
To ensure that the patient
Explain and discuss the procedure with the patient.
understands and gives his/her
consent.
To prevent contamination of
Clean tray and whilst drying gather equipment
equipment
Wash hands with soap and water or apply alcohol based
To minimise infection and
hand rub. Apply non sterile gloves (use sterile gloves if you
prepare for procedure.
have to touch key parts).
Prepare the appropriate flush. Protect key parts using ANTT
To avoid introduction of infection
Page 40 of 65
principles.
If the patient’s line needs exposing access the IV device,
dispose of gloves and re-clean hands. Re-apply non sterile
gloves (use sterile gloves if you have to touch key parts).
To avoid introduction of infection
Clean connections with Chlorhexidine (2%) in 70% alcohol
equipment wipe before disconnection of any lines. Allow to
dry.
To minimise infection at
connection sites.
Aspirate a small amount of blood (enough to have
flashback) into the line to check for patency If unable to then refer to persistent withdrawal occlusion algorithm page
18. (for Hickman lines withdraw 10mls of blood to remove
the residual heparinised saline from the line from the last
flush).
To check the catheter has not
migrated or formed a fibrin
sheath/clot at the end.
Attempt to flush port with correct solution syringe type and
method (see above). Lines with clamps – ensure the line is
clamped in the closed position before removing any
obturators and attaching. The syringe on open ended lines.
Open the clamp once the syringe is attached then adopt
correct method of flush.
Dispose of sharps and equipment then dispose of gloves.
Clean tray
Wash hands with soap and water or apply
Ensure patient is made comfortable.
Sign the prescription sheet.
To avoid administration of
heparin.
Smaller syringes than 10 ml
create excessive pressure and
possible catheter rupture.
Patency can be better
maintained with correct
techniques.
Avoid introduction of air in the
line.
To prevent environmental
contamination.
alcohol gel.
To prevent cross infection
To comply with hand-washing
guidelines.
To document the flush.
5.8 Blood Sampling from Central Vascular Access Devices.
Principles
This guideline applies to all central venous access devices. There are variations between amount
aspirated from each different device and the amount of flush given. The table below illustrates the
differences. The types of flush and the method are as per the previous guidelines for flushing
vascular access devices
N.B. CVADs should not be considered as a routine method of blood sampling. They should only be
used if other sampling measures are difficult or frequent and on the basis of clinical need.
Device
Pre-sample aspirate amount
Page 41 of 65
Valved PICC/ Midlines (Bard).
2 - 5 ml.
Non-valved PICC lines (Vygon).
6 – 10 ml.
Non-tunnelled central catheters.
6 – 10 ml.
Skin-tunnelled catheters
(Hickman).
6 – 10 ml.
Procedure
Equipment.
1. Clean trolley or surface to prepare sterile area.
2. Sterile dressing pack with gloves, gauze and small sterile sheet/towel.
3. Apron
4. Chlorhexidine (2%) in 70% alcohol equipment wipe.
5. Alcohol based hand rub.
6. Sterile obturators/caps/needle free system.
7. 10ml/20ml syringes.
8. Prescribed flush solution - sodium chloride injection 0.9% and/or Heparin Sodium (50units/5ml).
Blood sampling from a central vascular access device
Action
Rationale
Explain and discuss the procedure
To ensure that the patient understands and
with the patient.
gives his/her consent.
Wash hands. Open dressing pack To minimise infection and prepare for
and other equipment onto sterile field. procedure.
Apply alcohol based hand rub.
Apply sterile gloves and clean
connections with chlorhexidine (2%)
in 70% alcohol equipment wipe
before disconnection of any lines.
Allow to dry.
To minimise infection at connection sites.
Aspirate the required amount from
the catheter
To get rid of mixed blood and flush solution
and get an uncontaminated sample.
Draw the sample using the
appropriate method (i.e. Monovette
system etc.)
To ensure the sample is obtained in the
best method for testing.
Flush port with correct solution
syringe type and method (see above)
Smaller syringes create excessive
pressure and possible catheter rupture.
Patency can be better maintained with
correct techniques.
Dispose of waste.
To prevent environmental contamination
Sign the prescription sheet.
To document the flush.
Page 42 of 65
5.9 Unblocking Central Vascular Access Devices.
Principles
Blockages may be caused by a blood clot forming or precipitate from drugs. They frequently occur
when an infusion has been off for a prolonged period or when flushing is inadequate. Lines can lie
against vessel walls making them appear blocked. In many cases ‘patient body position change
manoeuvres’ can be used to ascertain if this is the case. If this is not possible or successful a
negative pressure technique can be used to good effect.
In this procedure the equipment list is only a guide. The important task is to maintain asepsis by
ensuring the sterility of any object which comes into contact with an open catheter port (ANTT
principles). This includes all ports and connections.
This procedure should only be undertaken by medical/senior registered nursing staff that
have undertaken a period of education & supervised practice by a practitioner competent at
unblocking central vascular access devices.
Procedure
Equipment.
1. Clean trolley or surface to prepare sterile area.
2. Sterile dressing pack with gloves, gauze and small sterile sheet/towel.
3. Chlorhexidine (2%) in 70% alcohol equipment wipe
4. Alcohol based hand rub.
5. Non-sterile gloves, apron
6. Sterile obturators/caps/needle free system.
7. Three-way tap.
8. 10ml syringes.
9. Prescribed flush solutions - 0.9% Sodium Chloride injection and Heparin Sodium
(50units/5ml).
Unblocking a central vascular access device
Action
Rationale
Explain and discuss the procedure with the
To ensure that the patient understands
patient.
and gives his/her consent.
Wash hands. Open dressing pack and
other equipment onto sterile field. Apply
alcohol based hand rub.
Apply sterile gloves, clean connections with
chlorhexidine 2% in 70% alcohol swab
before disconnection of any lines. Allow to
dry.
To minimise infection and prepare for
procedure.
Attempt to flush port with sodium chloride
injection 0.9% in a 10ml syringe.
Smaller syringes may cause high
pressures and are at risk of rupturing
the line
If there is pressure within the lumen, gently
instil the sodium chloride injection 0.9%
using a ‘to and fro’ motion (push-pull).
To attempt to clear the catheter
To minimise infection at connection
sites.
Page 43 of 65
If nothing aspirated, attach a three way tap
and to this add an empty 10ml syringe and
a 10ml syringe containing Hepsal solution.
To commence the negative pressure
technique.
The negative pressure technique.
Turn tap to close off pre filled syringe and open it to empty syringe.
Aspirate on empty syringe, which creates a negative pressure.
Turn tap to close off empty syringe. The medication will automatically be aspirated
into the catheter.
Repeat if necessary.
If blood returns withdraw at least 10ml
and discard.
To ensure no fibrinolytic agent or clots
are flushed into the patient
Flush lumen with sodium chloride
injection 0.9% using a pulsatile flush then
flush with Hepsal solution.
To ensure the lumen is flushed and
patent
Dispose of waste.
To prevent environmental contamination
Wash hands.
Comply with hand washing guidelines
Sign the prescription sheet.
To document the flush.
5.10 Procedure for the removal of the Peripheral Intravenous Cannula and subcutaneous
needle
Procedure
Equipment
 Sterile gauze
 Tape
 Non-sterile gloves
 Plastic apron
 Plastic receiver incorporating sharps bin
Action
Explain the procedure to the patient.
(Alternative formats are available on
request e.g. translation services,
sign
Rationale
To ensure the patient understands and cooperates with the procedure.
Decontaminate hands using soap
language
induction
and waterservices,
or use alcohol
gel ifloop).
hands
visibly clean.
To reduce the risk of cross-infection.
Apply apron and close fitting nonsterile gloves.
To reduce the risk of cross-infection.
Page 44 of 65
Remove dressing and canola, apply
sterile gauze, pressure and secure
with tape
To reduce the risk of bacteria entering the
exit site.
Dispose of the cannula in the sharps
bin.
To reduce the risk of accidental sharps
injury.
Elevate the limb if bleeding persists.
To stop the bleeding.
Dispose of clinical waste as per
Hospital
Waste Disposal Policy No 15.
Remove and dispose of gloves in
yellow clinical waste bag.
Decontaminate hands as per point 2.
To ensure the correct disposal of clinical
waste. To maintain health and safety.
Record date and time of removal in
the patient’s notes.
To ensure the removal is documented.
To ensure the correct disposal of clinical
waste. To maintain health and safety.
To reduce the risk of cross-infection.
5.11 Procedure for removal of Central Vascular Access Devices.
Removal of CVADs’ must only be undertaken by medical staff and registered nurses/midwives who
have undertaken supervised practice in the removal of CVADs’.
Variations
Non-tunnelled
Device
central lines
Catheter/
make
All types
Specific cautions
When the catheter is removed air must be prevented from
entering the vessel and causing an air embolus. If the patient
can tolerate it, they should be placed in a lying down position.
If the patient is conscious and able to co-operate ask them to
hold their breath on inspiration.
If a patient is unable to co-operate or is ventilated, the catheter
can be withdrawn until the tip is still in situ, then on inspiration
the remainder of the catheter is quickly removed and pressure
applied with gauze.
Thick
lumen Added caution should be taken to avoid air embolus due to the
catheters (e.g. size of the insertion hole. The dressing should remain in situ for
dual
72hrs to prevent a delayed air embolism.
lumen dialysis
lines/ Swann
introducers)
Page 45 of 65
Peripherally
inserted
central
catheters
(PICC)
or
Midline
catheters
Bard
(PICC/ Midline)
Removal is as is with the non-tunnelled central line. The
catheter is more flimsy with the Bard system. It should be
withdrawn with a constant steady motion and not allowed to
over-stretch. Remove it parallel with the vein and grasp the line
every few centimetres as it is withdrawn. The tip has a closed
end and this signifies the line is intact.
Vygon
Removal is as is with the non-tunnelled central line. This is not
a flimsy line but still should be withdrawn grasping the line
every few centimetres. The tip is open and trimmed prior to
insertion. Length when trimming should be documented in the
notes.
Skintunnelled
catheters
Hickman
Removal is as is with the non-tunnelled central line. However
added traction will be needed on removing these lines. The
procedure may even require surgical excision.
Removal of these lines should only be undertaken
medical/senior nursing staff who have undertaken a period
of education & supervised practice by a practitioner
competent in the removal of skin tunnelled catheters.
Procedure
Equipment
 Apron
 Clean trolley or surface to prepare sterile area.
 Sterile dressing pack with gloves, gauze and small sterile sheet/towel.
 Chlorhexidine (2%) in 70% alcohol skin preparation.
 Alcohol based hand rub.
 Transparent semi permeable dressing.
 Sterile scissors.
 Sterile container to send tip for bacteriology (if infection suspected).
 Stitch cutter (if sutured) or Alcohol swab (if adhesive fixing device)
Removing a central vascular access device
Action
Rationale
Explain and discuss procedure with
To ensure patient understands and gives
patient.
his/her consent.
Screen bed area.
Wash hands.
Open dressing
equipment.
Maintain patient’s privacy
pack
and
sterile
Position patient as discussed above
Prepare for procedure and maintain sterile
field.
To reduce risk of air embolism
Page 46 of 65
Apply non-sterile gloves and carefully
remove and discard dressing into a
yellow bag.
To access site.
Wash hands or apply alcohol hand rub.
Minimise the risk of infection.
Apply sterile gloves and remove
sutures or adhesive device (if present).
Clean area with Chlorhexidine (2%) in
70% alcohol skin preparation.
To prevent contamination and false positive
when tip sent for bacteriology.
Cover insertion site with several layers
of sterile gauze.
Remove the catheter according to the
recommendations above applying
light pressure to the site with swabs.
Immediately after the end is removed
place catheter onto sterile sheet and
maintain firm pressure on the exit site
for a minimum of 2-5 minutes.
To absorb leakage of blood.
When bleeding has stopped cover site
with
transparent
semi-permeable
dressing. Use gauze if still oozing.
To prevent infection or air entry to the vein.
If infection suspected, carefully cut
approximately 5cm of catheter tip with
sterile scissors and collect in a sterile
container and send for microbiology.
Fold away contents of sterile field and
place in a yellow bag.
To identify any catheter related infections,
so they may be treated appropriately
Wash hands on removal of gloves
To comply with hand-washing guidelines.
Pressure
is
applied
to
prevent
haemorrhage, encourage resealing of the
vein, and prevent air entry into the vein.
To prevent contamination of the catheter
before being cut and sent for microbiology.
Reduce
risk
contamination.
of
environmental
Ensure patient is made comfortable
Document removal/tip sent in case
notes
To maintain accurate records
Page 47 of 65
6. Bibliography/References
1. ANTT (Aseptic non-touch technique) (2008). www.antt.co.uk
2. BARD Groshong PICC Placement Workshop Workbook. (9710R)
3. Department of Health (2007). Saving Lives: High Impact Intervention No 1. Central Venous
Catheter Care Bundle.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digital
asset/dh_078120.pdf
4. Donnelly M. (1999) -The Benefits of Hypodermoclysis. NursingStandard: 13. 15, 44-45.
5. Dougherty and Lister (2011) The Royal Marsden Hospital Manual of Clinical Procedures
8th Edition. Wiley & Blackwell.
6. http://www.royalmarsdenmanual.com/view/professional.html
7. Dougherty, L (2008) Peripheral Cannulation. Nursing Standard.22,52,49-59.
8. Higgins (2002) - Subcutaneous fluid administration in palliative care. Lothian Palliative
Care Guidelines Group.
9. Medical Device Alert (2008). Needle Free Intravascular Connectors. MHRA
10. http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON014380
11. NPSA (April 2008) – Rapid Response Report: Risks with Intravenous Heparin
12. http://www.nrls.npsa.nhs.uk/resources/?entryid45=59892
13. Competency framework for Peripheral Venous Cannulation in Children and Young people
14. http://www.rcn.org.uk/__data/assets/pdf_file/0010/78679/003003.pdf
15. Hypodermoclysis Working Group (1998) - Hypodermoclysis: Guidelines on thetechnique.
Wrexham: CP Pharmaceuticals (III).
16. Infection Control Nurses Association (April 2008) Hand Decontamination Guidelines.
Infection Control Nurses Association.
17. Ingram P and Lavery I (2007) Peripheral Intravenous Cannulation – Safe Insertion and
Removal Technique. Nursing Standard 22,1.44-48.
18. Morris W, Tay MH (2008) Strategies for preventing peripheral intravenous cannula
infection. British Journal of Nursing 17(19): S14–S21.
19. North Bristol NHS Trust (2009) - Hypodermoclysis Policy.
20. http://www.glospct.nhs.uk/pdf/policies/clinical/cp31%20sub%20cut%20fluids.pdf
21. Khan M, Younger G (2007) Promoting safe administration of subcutaneous infusions
Nursing Standard 21, 31, 50-56
22. Pratt RJ et al. (2007) Epic2: Developing national evidence-based guidelines for
preventing healthcare associated infections. Journal of Hospital Infection. 65S, S1–S64
23. http://download.journals.elsevierhealth.com/pdfs/journals/01956701/PIIS0195670107600024.pdf
24. Royal College of Nursing (2007) Standards of Infusion Therapy.
25. http://www.rcn.org.uk/__data/assets/pdf_file/0005/78593/002179.pdf
26. Sasson M & Shvartzman P. (2001) Hypodermoclysis:
an alternative infusion technique. American Family Physician; 64:1575–8.
27. Springhouse Corporation (2002) Intravenous Therapy Made Incredibly Easy. Springhouse,
Lippincott, Williams & Wilkins. Philadelphia.
28. Workhardt UK Ltd (2006) Drug information on Hyalase ® (Hyaluronidase for Injection BP).
http://www.medicines.org.uk/EMC/medicine/7315/SPC/Hyalase+1500+I.U.+Powder+for+Solu
tion+for+Injection+Infusion/
Page 48 of 65
Appendix A
Glossary of abbreviations
CVAD
CVC
PICC
TPN
VAD
VIP
Central vascular access device
Central venous catheter
Peripherally inserted central catheter
Total parental nutrition
Vascular access device
Visual Infusion Phlebitis Sc ore
Page 49 of 65
Appendix B
DEVELOPING THE SCOPE OF PROFESSIONAL PRACTICE
Clinical Competencies Acquisition
Inserting a Peripheral Cannula
This is for assessing the ability of staff to insert a Peripheral cannula
This workforce competence is linked to the following dimensions and levels in the NHS Knowledge
and
Skills Framework (October 2004)
(Pending)
How to use this competence assessment framework
This proforma framework should be completed whilst observing a member of staff inserting a
peripheral cannula. The procedure for the insertion and care of peripheral cannulas must be
adhered to.
It is important that the assessor informs the patient that the members of staff’s skills are being
assessed as part of a three-yearly process.
Name of member of staff:
Name of assessor/assessors:
Job title:
Job title:
Area of work:
Area of work:
Date of assessment:
Comments:
Page 50 of 65
Appendix C
Observational Assessment of Competency: Insertion of a peripheral Cannula
In order to achieve the competency, the student must be able to achieve the following
elements:
Element
Competent Yes/No
Further Practice Required
Preparation for procedure
Explains procedure to patient, gains
consent, asks patient history
Checks patient wrist band.
Gathers
checks
equipment.
and
assembles
Inspects potential cannulation sites,
palpates and selects most appropriate.
Washes hands, applies gloves/apron.
Insertion of the cannula
Applies tourniquet.
Checks for a radial pulse.
Cleanses site, demonstrating aseptic
technique.
Ensuring the cannula is in the bevel up
position, inserts the cannula at a
selected angle according to the vein.
Wait for the first flash back of blood in
the flashback chamber.
Level the device by decreasing the
angle between the cannula and the skin
and advance the cannula slightly
Slowly withdraw the stylet and a second
flashback of blood will be seen along the
shaft of the cannula.
With the non-dominant hand maintain
theposition of the stylet and using the
dominant hand slowly advance the
cannula off the stylet and into the vein.
Page 51 of 65
Release the tourniquet dispose of
introducer needle and attach obturator.
Clean the area, and dress with a
transparent semi permeable dressing
Flush with 5mls 0.9% sodium chloride
using a 10 ml syringe
Disposes of clinical waste appropriately
Documentation
Complete Care and Record of
Peripheral Cannula Sheet.
Assessor Initials
Date of Assessment
Page 52 of 65
Appendix D
Observational Assessment of Competency: Drawing up and administration of sodium
chloride for flushing for non registered staff
In order to achieve the competency, the student must be able to achieve the following
elements:
Element
Competent
Yes/No
Further Practice Required
Preparation for procedure
Gathers
checks
and
assembles
equipment. Washes hands and apply
gloves.
Check 0.9% sodium chloride ampoule
against the prescription sheet with a
registered nurse/midwife or medical staff
Withdrawing 0.9% sodium chloride from a plastic ampoule
Use of an aseptic non touch technique
(ANTT) – protecting key parts where
bacterial contamination may be introduced
i.e. those parts of equipment that come into
direct contact with the liquid infusion or the
patient e.g. syringe tips, needles, ampoule
tops etc
Open the syringe packaging carefully to
form a pocket so filled syringe can be
reinserted. Attach a 23g (green) needle to
a syringe and draw the required volume of
sodium chloride (5-10mls)
into the syringe tilting the ampoule if
necessary.
Invert the syringe and tap lightly to dislodge
any air bubbles at the needle end, expel
the air carefully.
Discard the needle into the sharps box
immediately and insert back into syringe
packet and place into ANTT tray with other
equipment.
Administration
Check patient’s name and date of birth with
prescription sheet.
Page 53 of 65
Using 2-5ml of 0.9% sodium chloride,
slowly flush the cannula via the injection
port using ANTT method.
NOTEFollowing insertion only because after use
the port will no longer be sterile.
Subsequent use of the port should be
avoided if possible. Observe for signs of
leakage, swelling. Ask the patient if any
discomfort is felt. If any of the above is
present remove the device and resite.
Remove gloves and wash hands.
Documentation
Record in patient prescription
following administration.
sheet
Assessor Initials
Date of Assessment
Page 54 of 65
Appendix E
Assessor Guidance



Unless indicated as not applicable (N/A) and a reason provided, all the above criteria must
be achieved to gain competency.
Staff new to cannulation must achieve at least 10 competent cannulations before being
signed off as competent to practice unsupervised.
All candidates must undertake a verbal knowledge assessment conducted by the assessor.
Knowledge Assessment
Did the candidate demonstrate an understanding of the importance of the following points?
Knowledge Assessment
Inspection and palpation
Selection of correct size of cannula, appropriate location of the device
Complications of cannulation
On going care of a cannula
Infection control issues, Aseptic non touch technique (ANTT)
How to deal with a needlestick Injury
Yes/No
Page 55 of 65
Appendix F
Assessment Record for Inserting a Peripheral Cannula
Name of member of staff:
Name of assessor/assessors:
Job title:
Job title:
Area of work:
Area of work:
Payroll number:
Date of assessment:
Having undertaken the above competency assessment the candidate achieved a:
PASS
REFERRAL
Please circle the appropriate action (any comments below)
Date for re-assessment (if appropriate): ………………………………………….
Candidate signature: ...........................................
Print Name: …………………………………………
Date: …………………
Signature of assessor: ...................................... Date: ……………………
Print name: …………………………………………..
Page 56 of 65
Appendix G
REFLECTIVE EVIDENCE OF CONTINUING PROFESSIONAL DEVELOPMENT
The nature of the learning activity:
Guidelines
Briefly describe the learning activity, for example, reading a relevant article, attending a course or
observing practice
Description of the learning activity:
What did it consist of, why did you decide to do the learning activity or how did the opportunity
come about, where, when and how you did the learning activity, and what you expected to gain from
it
The outcome of the learning activity
How did it relate to your work? What effect did the learning have on the way you work or intend to
work in the future? Do you have any ideas or plans for follow up learning.
Please remember confidentiality when undertaking reflective work. These reflections in line
with the clinical competencies are intended to help you use the information and skills
learned at the study session and apply them safely to your clinical practice.
Undertaking reflection is a CPD requirement for nursing and midwifery and is becoming an
expectation of other professions also.
REFLECTIVE EVIDENCE OF CONTINUING PROFESSIONAL DEVELOPMENT
WORK PLACE AREA:
NAME OF THE ORGANISATION:
Brief description of work role
NATURE OF THE LEARNING ACTIVITY: DATE:
Brief description:
Page 57 of 65
DESCRIPTION OF LEARNING ACTIVITY:
OUTCOME OF LEARNING ACTIVITY:
(How did the activity relate to your work/role?)
Page 58 of 65
Appendix H
Types of central vascular access devices used
Device
Peripherally
inserted
central
catheters
(PICC)
Midline
catheters
Nontunnelled
central lines
Skintunnelled
catheters
Right internal jugular
Examples and
manufacturers
Bard
(groshong-valve)
Vygon (open
ended)
Indications
Bard (groshongvalve)
Inserted into veins, usually at the level of the
antecubital fossa. Either stopping at the axilla or
the beginning of the central venous network. Only
for non-irritant peripheral medications and
medium-term usage (maximum of 4 weeks)
Directly inserted into large (central) veins, and the
tip rests in the inferior or superior vena cava (see
figure 1 overleaf for insertion sites). For short-term
to medium-term use (1-2 weeks).
Directly inserted into large (central) veins, and the
tip rests in the inferior or superior vena cava. The
line is tunnelled under the skin of the chest wall in
subcutaneous tissue. It is anchored in place by a
Dacron cuff, located under the skin. Either for
irritant medications and/or long-term use
(weeks/months). Removal of these lines must
only be undertaken by qualified personnel
Single, dual
(usually for
dialysis), triple or
quad lumen lines.
Hickman lines
Inserted into veins, usually at the level of the
antecubital fossa, and fed through to the superior
vena cava. Either for irritant medications and/or
long-term use (weeks/months).
Left internal jugular
Potential sites for central vascular access
device placement
Right subclavian
Right antecubital fossa
Right femoral
Left subclavian
Left antecubital fossa
Left femoral
Immediate post insertion of a central vascular
access device
A chest X-ray must be obtained to confirm
position immediately post-insertion. The line
must not be used until the position has
been confirmed. It is the responsibility of the
nurse in charge of the patient to have an
adequate care plan in place
Page 59 of 65












Appendix I
VISUAL INFUSION PHLEBITIS SCORE (VIP)
IV site appears healthy.
No pain
One of the following is evident:
Slight pain near IV site
Slight redness near IV site
No signs of phlebitis:
0
1
OBSERVE CANNULA
Possible first signs of
phlebitis:
OBSERVE CANNULA
Two of the following are evident:
Pain at IV site
Swelling
Erythema
All of the following are evident:
Pain along the path of the
cannula
Swelling
Erythema
All of the following are evident and
extensive:
Pain along the path of the
cannula
Swelling
Erythema
Palpable venous cord
All of the following are evident and
extensive:
Pain along the path of the cannula

Swelling

Erythema

Palpable venous cord

Pyrexia
Early stage of phlebitis:
2
RESITE CANNULA
REFER TO MEDIC
Medium stage of phlebitis:
3
4
RESITE CANNULA
REFER TO MEDIC &
CONSIDER TREATMENT
Advanced Stage of phlebitis
or start of thrombophlebitis:
RESITE CANNULA, REFER
TO MEDIC & CONSIDER
TREATMENT
Advanced stage of
thrombophlebitis:
5
RESITE CANNULA,
REFER TO MEDIC & INITIATE
TREATMENT
Adapted by Andy Turner & Alison Carroll from
Jackson, A. (1998) A battle in vein: infusion phlebitis. Nursing Times 48: 4, 68-71
March 2007 – Version 1
Page 60 of 65
Appendix J
PICC LINE PLACEMENT ASSESSMENT
The below mentioned has been assessed on the following competencies
Competency assessment framework to Perform PICC Line Placement
COMPETENCY
Achieved
(Y/N)
Preparation
Evaluates the patient for appropriateness for placement. Including
venous history and any relevant changes in clinical status.
Assess patients’ psychological status regarding procedure.
Procedure
Identifies self to patient.
Checks patients’ identity.
Ensures patient comfort throughout the procedure and takes action to
identify and reduce anxiety.
Assembles the equipment necessary to conclude the procedure safely
and efficiently.
Selects the appropriate vein for placement.
Prepares equipment and sterile fields safely.
Prepares insertion site.
Performs accurate venepuncture with the introducer needle.
Advances PICC to the proper tip location while positioning patient
head to the affected side.
Removes guide wire and aspirates for blood return.
Flushes device appropriately and applies luer lock injection cap.
Secures PICC properly and applies sterile dressing.
Disposes of drugs, equipment and waste efficiently and safely.
Recognises own limitations with difficult veins and refers on to more
experienced cannulator appropriately.
Analyses difficulties occurring during the procedure and potential
reasons for these.
Identifies complications that may arise following the insertion of the
PICC line.
Ensures that an appropriate person checking the chest x-ray confirms
PICC position as correct.
Patient Education & Continuing Care
Explains procedure, including the risk of thrombosis, infection and
instructs patient and/or family to report adverse effects promptly and
from whom to seek help.
Ensures patient gives informed consent for the procedure. Give an
opportunity for patient and family to ask questions and answers
appropriately.
Signature of person assessed Print name
Position
Date
Signature of assessor
Date
Signature of appropriate
Medical officer
Date
Initial
Page 61 of 65
Appendix K
RECORD OF CONTINUOUS ASSESSMENT TO PERFORM PICC PLACEMENT.
Candidates Name……………………………. Supervisors Name…………………………………
Review
Date
Comments
Signature
of
Supervisor
Signature
of
Candidate
Page 62 of 65
Appendix L
Assessment Record for Inserting a Peripheral Cannula
Name of member of staff:
Name of assessor/assessors:
Job title:
Job title:
Area of work:
Area of work:
Payroll number:
Date of assessment:
Having undertaken the above competency assessment the candidate achieved a:
PASS
REFERRAL
Please circle the appropriate action (any comments below)
Date for re-assessment (if appropriate): ………………………………………….
Candidate signature: ...........................................
Date: ……………………………….
Print name: ………………………………………..
Signature of assessor: ...........................................
Date: ……………………………….
Print name: …………………………………………..
Page 63 of 65
Appendix M
Algorithm - Persistent Withdrawal Occlusion
i.e. fluids can be infused freely by gravity but blood cannot be withdrawn from the
catheter (London Standing Committee 2000) cited in Royal College of Nursing (2007)
Standards of Infusion Therapy
Ask patient to cough, deep breathe,
change position, stand up or lie with
foot of the bed tipped up Ascertain
possible cause of PWO
Blood return is
absent
Flush central venous catheter
with 0.9% Sodium chloride in
10ml syringe using a brisk ‘push
pause’ technique. Check for
flashback of blood
Blood return
obtained – use central venous
catheter as usual
Blood return is still
absent
Patient to receive highly
irritant/vesicant drugs or
chemotherapy
Blood return is still absent
NO
YES
Proceed if happy to do so as
long as there are no other
complications or pain
The following steps should initially be done on admission or prior to
drug administration and documented in nursing care plan so that all
staff are aware that patency has been verified
Step 1
Administer a 250ml normal saline ‘challenge’ via an infusion pump
over 15 minutes to test for patency - the infusion will probably not
resolve the lack of blood return (unless the patient has a high sodium
or is on restricted fluid - go to step 2).
If there have been no problems, therapy can be administered
as normal. If the patient experiences ANY discomfort or there is any
unexplained problems then stop and seek medical advice. It may be
necessary to verify tip location by chest X-Ray.
OR
Step 2
Instil Urokinase 5000iu in 2 mls and leave for 60 minutes. After this
time withdraw the urokinase and assess the catheter again. Repeat as
necessary. If blood return is still absent, it may be necessary to verify
tip location by chest X -ray.
Page 64 of 65
Appendix N
Bard PICC Line Record Chart
Addressograph
24HR DRESSING CHANGE :____________________
WARD :____________
SUTURES REMOVED:_________________________
7 Day Dressing, needle
free device and Stat
Lock Change
DATE OF REMOVAL :_________________________
Flush and Inspection (CVAT Score) Chart
DATE
&
TIME
CVAT
SCORE
SIGN
FLUSH
SIGN
DATE
&
TIME
CVAT
SCORE
SIGN
FLUSH
SIGN
DATE
&
TIME
CVAT
SCORE
SIGN
FLUSH
SIGN
DATE
&
TIME
CVAT
SCORE
SIGN
DATE
TIME
SIGN
FLUSH
SIGN
Page 65 of 65