CVAD ManagementTraining

Royal Children’s Hospital

Melbourne, Australia

ContentsSelecting the right technique

Preparation

Procedures:• Administration of medicines• Changing IV Bags / Syringes• Changing IV lines • Taking blood samples

Summary

CVAD infections – the facts

Why we need to be vigilant in CVAD care

CVAD infections – the facts

• In Australia approximately 150,000 Healthcare Associated Infections (HAI’s) contribute to 7,000 deaths each year

• CVAD-associated blood stream infections are responsible for 20 - 40% of HAI in both paediatric and adult patients

• Management cost estimates for a single line infection are between A$10,000 and A$15,000

CVAD infections – the facts

• At RCH CVAD infection rates vary between 3 and 13 per 1,000 line days

• Other hospitals have reduced their infection rate to below 1 per 1,000 line days by implementing improvements to the quality of aseptic technique

• Some hospitals have remained at zero infections for months, even years at a time

CVAD management

Choosing the right

technique

Which technique should I use?

• Low risk procedures• Non-touch:

• Administering medicines

• Flushing line• Changing IV bags/

syringes• Priming, connecting/

disconnecting IV lines to smartsite

• Taking bloods

• High risk procedures• Sterile technique:

• Changing caps or Smartsites

• Changing CVAD dressings

• Accessing an infusaport

Or put another way:

• Non-touch procedures are used when connecting to a smartsite or changing IV bags or syringes

• Sterile procedures are used when the patient’s lumen is open or the site of CVAD entry to the skin is exposed

Note: All of the procedures contained in this section are conducted using non-touch technique

Non-touch technique

Principles and practice of non-touch technique

Non-touch technique principles: key parts

• If key parts are contaminated by micro-organisms, the risk of infection is increased

• Key parts within IV therapy are parts of equipment that come into direct contact with a liquid infusion, for example:

• Needles• Syringe tips• IV line connections• Smartsite tip

Examples of key parts

Principles of non-touch technique:

• Use the correct hand cleaning technique

• Identify and protect the ‘key parts’ at all times

• Maintain a clean field

• Touch non ‘key parts’ with confidence

Important points:

• Sterile gloves and pack are not required for non-touch technique

• Non-sterile gloves should be worn for personal protection when required for procedures such as:

• Blood sampling, handling potentially harmful medicines, hanging blood infusions

• If allergic/sensitive to chlorhexidine, use gloves to protect hands from swab

• When preparing equipment, a large clean surface is required eg. large silver trays, procedure trolley

Important points:

• Needle free access ports (Smartsites) should be used to maintain a closed system wherever possible

• Use luer-lock syringes as a preference to ensure a good connection with Smartsite

• Three way taps should be avoided wherever possible to reduce internal surfaces of lines, and number of connections

Preparation for non-touch technique

The preparation of non-touch technique in the ‘clean drawing up’ room, or at the bedside

• Ensure workbench clean and free of clutterEnsure workbench clean and free of clutter• With clean hands, gather tray, medications & equipment With clean hands, gather tray, medications & equipment • If tray/surface is not clean, wipe thoroughly with alcoholIf tray/surface is not clean, wipe thoroughly with alcohol• Use an Use an appropriate size trayappropriate size tray - taking bloods may require a larger - taking bloods may require a larger

tray than administering antibioticstray than administering antibiotics

• Due to hand contamination from collecting equipment and Due to hand contamination from collecting equipment and touching cupboard handles etc, your touching cupboard handles etc, your asepticaseptic hand clean hand clean should occur should occur AFTERAFTER you have gathered everything you have gathered everything

• Ensure hands and forearms are bare of jewellery, sleeves and Ensure hands and forearms are bare of jewellery, sleeves and wristwatch wristwatch

• Ensure lanyard not hanging over hands or key partsEnsure lanyard not hanging over hands or key parts• Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Clean hands thoroughly using ALCOHOL GEL (15 seconds) or

Chlorhexidine 2% soap & water (30 seconds)Chlorhexidine 2% soap & water (30 seconds)• Ensure all surfaces of hands and wrists are cleanedEnsure all surfaces of hands and wrists are cleaned

• Open equipment onto tray carefully Open equipment onto tray carefully • Leave equipment in ‘clear packaging’ to assist with safe Leave equipment in ‘clear packaging’ to assist with safe

technique and decreased risk of contaminating key parts technique and decreased risk of contaminating key parts • Always leave vials & medications outside tray Always leave vials & medications outside tray

Remember:Remember: You are aiming for asepsis, not sterility You are aiming for asepsis, not sterility

• If wearing non sterile gloves, put them on at this stageIf wearing non sterile gloves, put them on at this stage• Gloves are worn for Gloves are worn for your own protectionyour own protection so be aware of the so be aware of the

products you are handling products you are handling

• Connect all key parts using a non touch technique eg needles Connect all key parts using a non touch technique eg needles to syringesto syringes

• Touch non key points with confidenceTouch non key points with confidence

• Prepare medications using non touch technique Prepare medications using non touch technique • Always useAlways use needlesneedles for ampoules and rubber capped bottles for ampoules and rubber capped bottles

• Use Use red capsred caps on syringes when going to patients on syringes when going to patients • Label syringes to ensure you know which is whichLabel syringes to ensure you know which is which• After medications correctly checked by RNs, dispose of After medications correctly checked by RNs, dispose of

packaging, needles & vialspackaging, needles & vials• Remove gloves if not immediately performing procedure or if Remove gloves if not immediately performing procedure or if

moving between roomsmoving between rooms

Things not to do:

• Don’t leave key parts or needles unprotected or exposed

• Don’t place vials in tray to identify drugs- they often leak around needles. Use stickers instead.

• Don’t clutter tray with unnecessary items

• Don’t ‘flick off’ key parts such as needles or caps

Remember non touch

Things not to do:

• Don’t break open packaging

Things not to do:

Medication administration

Administration of medicines using non-touch technique at the bed side

• Enter patient’s room and place tray in a safe positionEnter patient’s room and place tray in a safe position• Explain procedure to patientExplain procedure to patient• Expose patient’s line and smart siteExpose patient’s line and smart site• Allow sufficient open space around access pointAllow sufficient open space around access point

• Ensure hands and forearms are bare of jewellery, sleeves and Ensure hands and forearms are bare of jewellery, sleeves and wristwatch wristwatch

• Ensure lanyard not hanging over hands or key partsEnsure lanyard not hanging over hands or key parts• Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Clean hands thoroughly using ALCOHOL GEL (15 seconds) or

Chlorhexidine 2% soap & water (30 seconds)Chlorhexidine 2% soap & water (30 seconds)• Ensure all surfaces of hands and wrists are cleanedEnsure all surfaces of hands and wrists are cleaned

• If wearing non-sterile gloves for personal protection, apply If wearing non-sterile gloves for personal protection, apply them at this stagethem at this stage

• Keep tray close to your access pointKeep tray close to your access point

• Clean Smartsite Clean Smartsite vigorouslyvigorously with chlorhexidine & alcohol swab with chlorhexidine & alcohol swab• Allow to dry… at least Allow to dry… at least 20 seconds20 seconds

• Administer medications using non touch technique Administer medications using non touch technique • If infusion is not running, aspirate first to verify line is patentIf infusion is not running, aspirate first to verify line is patent• It is not necessary to clean the hub between syringesIt is not necessary to clean the hub between syringes• Flush line with normal saline using a pulsatile action (if Flush line with normal saline using a pulsatile action (if

disconnecting, use heparin and clamp with positive pressure) disconnecting, use heparin and clamp with positive pressure)

Safe injection of fluidsSafe injection of fluids

1) Syringes 10ml or more should be used to administer 1) Syringes 10ml or more should be used to administer a drug 'push' into the CVADa drug 'push' into the CVAD

2) If you 2) If you mustmust use a syringe <10ml, push very slowly to use a syringe <10ml, push very slowly to avoid generating high pressures avoid generating high pressures

3) If line accessed intermittently, aspirate first to ensure 3) If line accessed intermittently, aspirate first to ensure catheter is patent before injecting fluidcatheter is patent before injecting fluid

4)If the catheter does not aspirate, consult more senior 4)If the catheter does not aspirate, consult more senior staff, and see clinical guidelinestaff, and see clinical guideline

• Dispose of equipment immediately after procedure Dispose of equipment immediately after procedure • Dispose of glovesDispose of gloves• Immediately clean hands with alcohol gel or by washing Immediately clean hands with alcohol gel or by washing

Changing IV Bags and Syringes

•This procedure can be conducted using non-touch technique

•Bags and syringes should be changed every 24 hours

• Remove new IV bag from outer wrapper and hang on standRemove new IV bag from outer wrapper and hang on stand• Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Clean hands thoroughly using ALCOHOL GEL (15 seconds) or

Chlorhexidine 2% soap & water (30 seconds)Chlorhexidine 2% soap & water (30 seconds)• Don gloves if required for personal protectionDon gloves if required for personal protection

IV Bags:IV Bags:

• Remove tab using non-touch techniqueRemove tab using non-touch technique• Remove old solution from drip stand and tip upside downRemove old solution from drip stand and tip upside down• Remove giving set spike carefullyRemove giving set spike carefully

IV Bags:IV Bags:

• Without touching any key parts, insert spike into new bagWithout touching any key parts, insert spike into new bag• Discard empty bag in trash or if containing liquid, retain for Discard empty bag in trash or if containing liquid, retain for

subsequent draining and discard in pan roomsubsequent draining and discard in pan room• Perform hand hygiene immediatelyPerform hand hygiene immediately

IV Bags:IV Bags:

• Stop infusion pump, clamp IV line and syringeStop infusion pump, clamp IV line and syringe• Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Clean hands thoroughly using ALCOHOL GEL (15 seconds) or

Chlorhexidine 2% soap & water (30 seconds)Chlorhexidine 2% soap & water (30 seconds)• Remove syringe from pumpRemove syringe from pump• Remove extension tubing from old syringeRemove extension tubing from old syringe

Syringes:Syringes:

• Clean smartsite at end of extension tubing Clean smartsite at end of extension tubing vigorouslyvigorously with with swab and allow to dry for swab and allow to dry for 20 seconds20 seconds

• Without touching the key parts, remove cap from syringe and Without touching the key parts, remove cap from syringe and attach extension tubingattach extension tubing

• Note:Note: certain medications may require a three way tap on the certain medications may require a three way tap on the end of syringeend of syringe

• Perform hand hygiene immediately afterwardsPerform hand hygiene immediately afterwards

Disconnecting/reconnecting lines

• Line disconnections should be kept to an absolute minimum to reduce possible portals of infection and risk of occlusion

• If line is connected via a smartsite, this can be performed as a non-touch procedure

• Important: certain CVAD’s, such as neonatal small bore (<5Fr) and right atrial (RA) lines should not be disconnected at any time

Changing IV lines

• Priming and changing IV fluid lines

• This can be conducted as a non-touch procedure

Changing IV lines

• Replace IV lines every 3 days• Replace lines if disconnected more than 6 hours

• If using blood products:• Replace lines at the end of infusion or 24-hour intervals

• If using Parenteral Nutrition:• Replace tubing used to administer lipid emulsion

(including those combined with an amino acid and glucose in a 3:1 admixture eg Baxter TPN) within 24 hours of commencing the infusion.

• If nutrient and lipid are running via separate lines, only the lipid needs to be changed at 24 hours

• Prime and set up new line using non touch aseptic techniquePrime and set up new line using non touch aseptic technique• Ensure new lines are capped and not touching anythingEnsure new lines are capped and not touching anything

• Ensure forearms are bare of jewellery, sleeves and wristwatch Ensure forearms are bare of jewellery, sleeves and wristwatch • Ensure lanyard not hanging over hands or key partsEnsure lanyard not hanging over hands or key parts• Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Clean hands thoroughly using ALCOHOL GEL (15 seconds) or

Chlorhexidine 2% soap & water (30 seconds)Chlorhexidine 2% soap & water (30 seconds)• Ensure all surfaces of hands and wrists are cleanedEnsure all surfaces of hands and wrists are cleaned

• Open Chlorhexidine swab and carefully remove from packetOpen Chlorhexidine swab and carefully remove from packet

• Clean access point and hub vigorously with swab using a Clean access point and hub vigorously with swab using a rotating motion using thumb for pressurerotating motion using thumb for pressure

• Allow to air dry for Allow to air dry for 20 seconds20 seconds

• Ensure giving set is primed appropriatelyEnsure giving set is primed appropriately

• Disconnect cap from giving setDisconnect cap from giving set

• Connect new giving set to smartsite without touching key partsConnect new giving set to smartsite without touching key parts

Taking blood samples

How to take blood using

a non-touch technique

• Aim to collect all specimens Aim to collect all specimens at onceat once to minimize access to minimize access • With clean hands, gather equipment including a clean trayWith clean hands, gather equipment including a clean tray• Open and lay out equipment using non touch technique Open and lay out equipment using non touch technique • As before, clinically wash or gel handsAs before, clinically wash or gel hands

• Explain procedureExplain procedure• Place tray close to patient, expose line for easy accessPlace tray close to patient, expose line for easy access• If entering a new area, re-clean hands & don non-sterile glovesIf entering a new area, re-clean hands & don non-sterile gloves

• Clean access point and hub Clean access point and hub vigorouslyvigorously with chlorhexidine and with chlorhexidine and alcohol swabalcohol swab

• Allow to dry for Allow to dry for 20 seconds20 seconds

• Note:Note: if accessing a multi-lumen line, clamp other lumens if accessing a multi-lumen line, clamp other lumens before withdrawing bloodbefore withdrawing blood

• Infusions that should not be stopped, such as inotropes should Infusions that should not be stopped, such as inotropes should not not be clampedbe clamped

• Place 10 ml luer-lock syringe onto smartsite (if using slip Place 10 ml luer-lock syringe onto smartsite (if using slip syringes, insert and give a quarter twist to lock in place)syringes, insert and give a quarter twist to lock in place)

• Gently and evenly pull blood through line into syringeGently and evenly pull blood through line into syringe• If taking blood gases, aspirate directly into blood gas syringeIf taking blood gases, aspirate directly into blood gas syringe

• 1st syringe1st syringe may be used for blood cultures or discarded may be used for blood cultures or discarded • 5ml is a standard discard5ml is a standard discard• This blood can be re-infused in some patient groups, eg. This blood can be re-infused in some patient groups, eg.

neonatesneonates

• 2nd syringe2nd syringe is used for blood specimen/s is used for blood specimen/s• 3rd syringe3rd syringe is used for line flushing is used for line flushing • Flush using a pulsatile action (if disconnecting, use heparin Flush using a pulsatile action (if disconnecting, use heparin

and clamp with positive pressure)and clamp with positive pressure)

• Place blood into tubes carefully, filling EDTA tubes firstPlace blood into tubes carefully, filling EDTA tubes first• Collect and dispose of equipment safely Collect and dispose of equipment safely • Remove gloves, clean hands with alcohol gelRemove gloves, clean hands with alcohol gel• Label, date, time and initialLabel, date, time and initial • Put in transport bag and sign cardPut in transport bag and sign card• Clean handsClean hands

Summary

Summary

• CVAD infections can be a source of harm and sometimes death, but they can be prevented

• Disinfecting hands effectively before all line interventions will reduce CVAD related sepsis

Summary

Follow the key principles of non-touch technique:• Use the correct hand cleaning technique • Identify and protect the ‘key parts’ at all times• Maintain a clean field• Touch non ‘key parts’ with confidence