CVAD ManagementTraining

Royal Children’s Hospital

Melbourne, Australia

ContentsIntroduction

Selecting the right technique

Procedures• Changing smartsites• Changing dressings• Accessing infusaports

Daily line review

Summary

Preventing CVAD infections

• In part one of this package we showed that CVAD infections can cause expense, harm and sometimes death

• At RCH we are aiming to reduce our infection rate to below 1 per 1,000 line days in all areas of the hospital

• What is the infection rate in your area? Is it below the target?

CVAD management

Choosing the right

technique

Which technique should I use?

• Low risk procedures• Non-touch:

• Administering medicines

• Taking bloods• Flushing line• Changing IV bags/

syringes• Priming, connecting/

disconnecting IV lines to smartsite

• 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: This section demonstrates ‘sterile’ procedures using sterile pack and gloves

Smartsite change

• Smartsites should be changed every 6 days

• Sterile technique can be performed by 1 or 2 operators

• 1 operator technique can be performed if operator is competent and confident in performing the procedure on their own

• Wipe trolley/bench thoroughly with alcoholWipe trolley/bench thoroughly with alcohol• With clean hands, gather equipmentWith clean hands, gather equipment

• With clean hands, open equipment on trolleyWith clean hands, open equipment on trolley• Perform hand hygiene and put sterile gloves onPerform hand hygiene and put sterile gloves on

• Draw saline with a needleDraw saline with a needle• Prime the smartsitePrime the smartsite• Always discard used equipment away from sterile field Always discard used equipment away from sterile field

• Clean connection thoroughly, 3cm on both sides of connection Clean connection thoroughly, 3cm on both sides of connection moving away from connection site moving away from connection site

• Then around the connection siteThen around the connection site

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

• 2 person procedure: the helper will clamp the catheter2 person procedure: the helper will clamp the catheter• 1 person procedure: operator to clamp the catheter1 person procedure: operator to clamp the catheter• The operator to disconnect old smartsite and discard away The operator to disconnect old smartsite and discard away

from sterile field from sterile field • If any substance visible on exposed lumen, clean using new If any substance visible on exposed lumen, clean using new

gauze gauze

• Connect new smartsiteConnect new smartsite

• Unclamp the catheter:Unclamp the catheter:• 2 person procedure: helper to unclamp the catheter2 person procedure: helper to unclamp the catheter• 1 person procedure: operator to unclamp the catheter1 person procedure: operator to unclamp the catheter

• Flush and withdraw to check for blood and flush again to clear Flush and withdraw to check for blood and flush again to clear the line using a pulsatile action (if disconnecting, use heparin the line using a pulsatile action (if disconnecting, use heparin and clamp with positive pressure) and clamp with positive pressure)

• Remove syringe and discardRemove syringe and discard

Dressing change

• Dressings should be changed every 6 days

• Sterile technique can be performed by 1 or 2 operators

• 1 operator technique can be performed if operator is competent and confident in performing the procedure on their own

• Remove dressing:Remove dressing:• 2 people: the helper removes dressing with non sterile gloves2 people: the helper removes dressing with non sterile gloves• 1 person: remove dressing and discard from sterile field. Perform 1 person: remove dressing and discard from sterile field. Perform

hand hygiene and don new sterile gloveshand hygiene and don new sterile gloves

• Clean site with 0.5% chlorhexidine and 70% alcohol in a Clean site with 0.5% chlorhexidine and 70% alcohol in a circular motion, extending out around 5-10 cm diameter three circular motion, extending out around 5-10 cm diameter three timestimes

• allow to air dryallow to air dry

• Clean down the lines away from the patientClean down the lines away from the patient• Allow to Allow to air dryair dry

• Apply dressing either flat or as a sandwichApply dressing either flat or as a sandwich• In some cases eg. allergy, an alternative dressing may be In some cases eg. allergy, an alternative dressing may be

required, determined on an individual patient basisrequired, determined on an individual patient basis

Accessing an infusaport

• Ports need to be accessed using a sterile technique• Port needles should be changed every 6 days• This procedure can be traumatic and uncomfortable, so prepare patient carefully• Apply local anaesthetic cream prior to procedure

• Wipe trolley/bench thoroughly with alcoholWipe trolley/bench thoroughly with alcohol• With clean hands, gather equipmentWith clean hands, gather equipment

• Open equipment on trolley Open equipment on trolley • Choose needle gauge according to patient sizeChoose needle gauge according to patient size• Perform hand hygiene and put sterile gloves onPerform hand hygiene and put sterile gloves on

• Draw saline with a needleDraw saline with a needle• Prime huber needle Prime huber needle • Prepare set up before bringing patient into room as this Prepare set up before bringing patient into room as this

decreases stress of patientdecreases stress of patient

• Remove emla or angel creamRemove emla or angel cream• Wash hands or alco-gel and don sterile glovesWash hands or alco-gel and don sterile gloves• Clean using chlorhex & alcohol, in a circular motion from Clean using chlorhex & alcohol, in a circular motion from

centre of port ,extending out 5-10 cm diameter three timescentre of port ,extending out 5-10 cm diameter three times• Allow to air dryAllow to air dry

• Find the edges of the port Find the edges of the port • Hold edges between thumb and index fingerHold edges between thumb and index finger

• Press the needle through the skin using gentle, but steady Press the needle through the skin using gentle, but steady pressure until the needle touches the bottom of the portpressure until the needle touches the bottom of the port

• Gently flush port and withdraw to check for blood then flush Gently flush port and withdraw to check for blood then flush again to clear lineagain to clear line

• Insert folded gauze under needle for supportInsert folded gauze under needle for support

• Apply Steristrips to secure needleApply Steristrips to secure needle

• Apply transparent dressingApply transparent dressing• Anchor line with tape and safety pin to clothingAnchor line with tape and safety pin to clothing

Daily Line Review

• CVADs often remain in longer than required for treatment simply because removal has not been considered, or are kept ‘just in case’

• The longer a CVAD remains insitu, the greater the infection risk

Daily Line Review

• To prevent delays in removing unnecessary lines

• Multidisciplinary team must review line daily• Questions to ask

• How long has the line been in for?• Is central access necessary?• Are there alternative methods for access/treatment

• CVADs no longer required for patient care should be removed immediately

Daily line review

• Each day, the following should be documented on the CVAD observation chart MR114:

• Number of days the line has been in for• Reason for access• Whether the line is still required

Adverse Events

• Accidental disconnection• Immediately clamp catheter/line between leak and

patient• Using aseptic technique, clean patient side connection• Withdraw air (if present) and check for blood return• Flush with normal saline• Prime new lines and continue infusion• Notify RMO to assess patient if required prior to

continuing infusion

• Blocked lines• Refer to Anticoagulation Therapy Guidelines

Adverse Events• Suspected infection

• Observe every shift for early signs of infection (record on MR114)

• Notify RMO to assess patient if required• Superficial infection

• Swab site and smear glass slide for microscopy prior to placing swab in charcoal medium

• Send specimens to bacteriology• Systemic infection

• If temperature 38°C, take blood cultures from peripheral and central lines

• Samples should be taken from all lumens and these clearly labeled

Documentation

• MR114 (CVAD Observation Chart)• Insertion• Dressing• Adverse Events / Variances

• MR52 (Medication Chart)• Heparin locks

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

• Use sterile technique for high risk procedures

• Review CVAD’s daily, if they are not needed, remove without delay

• If in doubt – ask a senior member of staff