IV MEDICATION MANAGEMENT AND SUB …...peripheral lines, and sub-cutaneous fluids, in the community once they have been inserted. 1.3 In order for trained nurses to be able to complete

IV MEDICATION MANAGEMENT AND SUB-CUTANEOUS FLUIDS POLICY

Guideline Reference: 1685 Version: 1.3 Status: Adopted Type: Clinical Policy Guideline applies to (Staff Group) All West Suffolk Hospital Employed SCH Staff working As part of transition to the new service contract this Suffolk Community Healthcare (Serco) procedural document has been adopted by West Suffolk NHS Foundation Trust with the following amendments:

• Pg. 2 Heading amended to be consistent with front cover

• Pg.2 removal of statement of overarching principles

• Pg.2 section 1 SCH replaced with WSH (as referring to organisation)

• Pg.2, 4.2 amended to state ‘within SCH services’.

• Pg.4, 10.1 appraisal replaced by ‘performance development review’ to be consistent with acronym used.

• Pg.6, Appendix 1 – SCH replaced by WSH. EU Needle Safety Directorate replaced with ‘Directive’

• Pg.19 Changing site and giving set point 5 – added ‘ and documented’

• Version change to 1.1 – minor amendment as above

This policy will benefit from early review to ensure that citations are appropriately referenced. Where the procedural documents refer to Suffolk Community Healthcare (SCH) this is referring to those staff employed by West Suffolk NHS Foundation Trust as part of the Suffolk Community Healthcare Consortia, with The Ipswich Hospital NHS Trust and Norfolk Community Healthcare and Care Trust. Following a 30 day settling in period, a programme of review for all SCH procedural documents aligned with West Suffolk NHS Foundation Trust will be reviewed in consultation with subject matter experts and Suffolk Community Healthcare staff. Date Adopted: 30 September 2015

Review Date: No later than 31 December 2015

S/Internal/IV&SCFluidsPolicy/Oct16/V1.3

IV MEDICATION MANAGEMENT AND SUB-CUTANEOUS FLUIDS POLICY Document Reference: SCH Serco CP8 Version: 1.0

Status: Approved

Type: Clinical

Policy applies to: Community Hospital and Community Settings

Policy applies to: All appropriate clinical staff involved in the care of IV management and Sub-cutaneous fluids

Required compliance: This policy must be complied with fully at all times by the appropriate staff. Where it is found that this policy cannot be complied with fully, this must be notified immediately to the owner through the waiver process

Policy owner: Director of Nursing, Therapies and Governance Policy author: Practice Development Facilitator Other contact: Clinical Effectiveness Manager Date this version adopted December 2014 Reviewer N/A Last review date New policy Next review date December 2017 Location of electronic master SCH “S” Drive

AGREED DOCUMENT RATIFICATION / ADOPTION PATH:

Level 1:

Agreed by: Clinical Policy & Guidelines Group Date: 9/12/14

Level 2: Agreed by: Clinical Quality & Safety Assurance Group Date: 16/12/14

Level 3:

Agreed by: Senior Leadership Team (noting only) Date: January 2015

Level 4:

Agreed by: Date:


Contents

1 Introduction 1

2. Purpose of This Policy 1

3. Policy Agreement Path 1

4. Development of this Policy 1

5. Definitions 1

6. Cross Reference to Other Related Policies 2

7. Policy Statements 2

8. Summary of Roles and Responsibilities 3

9. Additional Resources Required 3

10. Additional Training Required 3

11. Review Period For This Policy 3

12. Communication of This Policy 3

13. Audit 4

14. Guidelines 4

Appendix 1: Cannulation; Insertion, administration and care 5

Appendix 2: Care of Midlines, PICC lines, and Central Catheters 10

Appendix 3: Procedure for taking blood samples from lines 12

Appendix 4: Procedure for any infusion/ all lines 14

Appendix 5: Guidelines for Sub-Cutaneous fluids 16

Appendix 6: Care, Maintenance and Access via a PORT-A-CATH. 19

Appendix 6a: Procedure for accessing and maintenance flushing of a PORT-A-CATH. 20

Appendix 6b: Procedure for maintenance flushing of a PORT-A- CATH 21

Appendix 6c: Procedure to allow access to a PORT-A-CATH for intravenous therapy 24

Appendix 6d: Procedure for taking a blood sample from a PORT-A-CATH 25

Appendix 6e: Procedure to administer intravenous medications via an accessed PORT-A-CATH 28

Appendix 6f: Procedure guideline for unblocking a PORT A CATH occlusion 30


IV MEDICATION MANAGEMENT AND SUB-CUTANEOUS FLUIDS POLICY

1 Introduction

1.1 West Suffolk NHS Foundation Trust requires that registered nurses have the knowledge, skill and competence required should they care for, insertion and/or administer drugs, obtain bloods or provide maintenance, to a patient via a PICC / GROSHONG / HICKMAN / MIDLINE / IMPLANTABLE PORT/CANNULAE (only device inserted outside of the acute setting), and sub-cutaneous fluids, within the Community Hospital or Community environment. The individual nurse has a responsibility in assessing their own practice in respect of this in accordance with the Code of Professional Conduct.

1.2 These guidelines outline the principles of good care from insertion to maintenance, and use of Central, peripheral lines, and sub-cutaneous fluids, in the community once they have been inserted.

1.3 In order for trained nurses to be able to complete the required care via a peripherally or Centrally Inserted Line they must have completed the relevant Intravenous (IV) study training. Annual update is recommended at a local level.

1.4 Staff will work in line with the SCH Policy for the Medicines Management (Safe and Secure Handling of Medicines) and the NMC Guidelines for the Administration of Medicines.

1.5 This guideline should be used in conjunction with the Infection Control Manual and the SCH Wound Care Formulary.

1.6 A nurse must NOT administer a drug they have not prepared.

1.7 Refer to the relevant hospital adult or paediatric Intravenous Drug Therapy Guidelines for each drug administration.

1.8 The administration of subcutaneous fluids can be carried out within the patient’s home environment once the assessing nurse can demonstrate safe technique in caring form the infusion.

2. Purpose of This Policy

2.1 This policy is intended to serve as a guide for all nurses, whose scope of practice encompasses these skills, in order to provide safe practice. It is recommended to refer to the electronic Marsden Manual, for further guidance, if required.

3. Policy Agreement Path

3.1 Detail which groups/committees will review/approve/ratify the Policy

4. Development of this Policy

4.1 This policy has been developed to cover all aspects of IV management and Sub-cutaneous fluid management, within SCH services.

4.2 Many patients are being admitted into hospitals, and the primary care setting, to receive IV, and Sub-cutaneous management. It is the responsibility of every healthcare professional involved to ensure they have received training, and continually update their knowledge with regards to the skills and risks associated with these forms of therapy.

5. Definitions

S/Internal/IV&SCFluidsPolicy/Oct16/V1.3 SCH Internal

• A MIDLINE is defined as one that is between 7.5cm and 20cm in length. It provides vascular access in a large vein without entering the central venous circulation. It is inserted into an ante-cubital vein and the tip is extended into the vein of the upper arm up to 20cm, but it is not extended past the axilla.

• A PICC (Peripherally Inserted Central Catheter) is a catheter that is inserted via the ante-cubital vein in the arm and is extended into the central veins, with the tip located in the SVC (Superior Vena Cava).

• A GROSHONG (Skin Tunnelled Catheter) is a long term catheter that lies in a subcutaneous tunnel before entering a central vein (usually sub-clavian). The tip lies at the junction of the SVC (Superior Vena Cava) and RA (Right Atrium) or within the lower portion of the SVC or the upper RA.

• A HICKMAN line is similar to the Groshong catheter and is inserted in the same way but does not have an integral value at the tip so therefore requires an external clamp

• An IMPLANTABLE PORT is a totally implanted vascular access device which is inserted into the chest wall. It requires access via gripper needles, (see Royal Marsden Manual Guidelines)

• A CANNULAE is a flexible tube containing a needle, which may be inserted in to a peripheral blood vessel. It is available in different gauges, dependent on its use.

• SUBCUTANEOUS FLUID is the method of delivering a volume of fluid, via a subcutaneous device. These devices are inserted into the subcutaneous tissues, mainly located on the arm, thigh, and chest wall.

6. Cross Reference to Other Related Policies

• SCH Infection Control Manual

• SCH Safe and Secure Handling of Medicines Policy

• SCH Wound Care Formulary

• Royal Marsden Manual Guidelines

• Standard Operating Procedure for Home IV Therapy (West Suffolk Hospital) available at: https://www.wsh.nhs.uk/Extranet/ClinicalGuidelinesandProtocols/CG10242HomeIVAntibiotics-StandardOperatingProcedure.pdf

• Patient Self-Administration of Intravenous (IV) Antibiotics (West Suffolk Hospital) available at home: https://www.wsh.nhs.uk/CMSdocuments/TrustPolicies/PDFs/301-350/PP(14)319PatientSelfAdministrationofIVAntibioticsatHomeSuffolkCommunityHealthcare.pdf

7. Policy Statements

7.1 There are 4 different types of patients that require IV therapy, within the community.

• Patients discharged from the acute hospitals, either via the virtual ward (WSH) and/or into our direct care. These patients will be managed via a PICC or Central Catheter.

• Patients commenced on IV therapy, and managed by the GP (General Practitioner) Practice, via the acute hospital. These patients will be managed via a PICC or Central Catheter.

• Patients commenced on IV therapy, and managed by the GP. These patients will be managed via Cannulae.


https://www.wsh.nhs.uk/Extranet/ClinicalGuidelinesandProtocols/CG10242HomeIVAntibiotics-StandardOperatingProcedure.pdf

https://www.wsh.nhs.uk/Extranet/ClinicalGuidelinesandProtocols/CG10242HomeIVAntibiotics-StandardOperatingProcedure.pdf

https://www.wsh.nhs.uk/CMSdocuments/TrustPolicies/PDFs/301-350/PP(14)319PatientSelfAdministrationofIVAntibioticsatHomeSuffolkCommunityHealthcare.pdf

https://www.wsh.nhs.uk/CMSdocuments/TrustPolicies/PDFs/301-350/PP(14)319PatientSelfAdministrationofIVAntibioticsatHomeSuffolkCommunityHealthcare.pdf

• Patients who are self-caring for their IV therapy. These patients will be assessed as competent following the Patient Self Administration of IV antibiotics at Home policy.

• The care and management for either of these types of patients are the same, and all guidelines must be followed. For those patients that are monitored via the ‘virtual wards’ staff are required to have read the SOP for home IV therapy, Appendix 1

7.2 Patients requiring subcutaneous fluid therapy are monitored via the GP.

7.3 All medication or substances that are due to be administered MUST be prescribed by a GP/Medical doctor, as per SCH Management of Medicine Policy. The only exception is Sodium Chloride 0.9%, used for flushing all devices.

8. Summary of Roles and Responsibilities

8.1 It is the responsibility of the Team Leads to:

8.1.1 Disseminate this guideline within their area of responsibility and ensure that staff are released to attend the mandatory training, and update knowledge and skills annually.

8.1.2 Ensure the implementation of the guidelines, and assist in the monitoring of its compliance and effectiveness.

8.2 It is the responsibility of all staff required to:

a) Use this guideline to familiarise themselves, raise any queries about the guidelines or their personal competency in implementing this guideline, as part of their professional practice.

b) All staff must also attend the IV training, complete the competency assessments, and show evidence of updating their knowledge, annually.

9. Additional Resources Required

9.1 If the implementation of the Policy is dependent upon additional resources these should be listed here.

10. Additional Training Required

10.1 IV therapy training is mandatory to attend for any new staff delivering this skill, or any existing staff member that has never attend training prior. It should then be addressed at the annual PDR (Personal Development Review), how knowledge and skills are being updated and maintained. Training can be booked via staff pathways, and a competency assessment must be completed.

10.2 Cannulation training is available, with competency assessments, via staff pathways, for those requiring the training.

10.3 Subcutaneous infusion training is currently not available and is expected to be delivered within teams, by experienced staff.

11. Review Period For This Policy

11.1 This policy will be reviewed every 3 years.

12. Communication of This Policy

12.1 Communication of this policy will be addressed at training sessions, and will be published within the following ‘take care, take note’ edition.


13. Audit

13.1 VIP audits to be completed monthly by relevant teams. Audit tool and calendars available at: http://nww.suffolkch.nhs.uk/Home/QualityGovernance/ClinicalAudit.aspx

14. Guidelines

14.1 Guidelines for the maintenance, administration, and care of all lines, and sub-cutaneous fluids are contained within the appendices of this policy


http://nww.suffolkch.nhs.uk/Home/QualityGovernance/ClinicalAudit.aspx

Appendix 1: Cannulation; Insertion, administration and care Selecting a Cannula All cannulae used within SCH need to comply with the EU Needle safety directive. The cannula of choice is currently BD Safe-T-Intima Integrated Catheter System, and this is reflected within the training. Cannula Gauge It is very important that the most clinically appropriate gauge of cannula is selected. The factors that should be considered are:-

• The type of medication that is likely to be administered through the cannula. Certain medication may require a wide bore cannula, due to its viscosity and potential to cause chemical phlebitis in smaller veins.

• The rate at which a fluid needs to administered over. • The availability of suitable veins to accommodate the cannula. • The incidence of complications increases with the increased size of the cannula. • Remember that the cannula selected should have the smallest gauge (external diameter) and the

shortest length that will be accommodated by the vein for the therapy that has been prescribed. • The smaller gauge cannula also ensures that the vein isn’t completely occluded and that there is

adequate blood flowing past the cannula this will prevent the drug having prolonged contact with the vein walls which could increase the risk of phlebitis or irritation.

Flow Rate

• The walls of the plastic tube should be thin enough to give the largest possible internal diameter; therefore a relatively small cannula can be used which will reduce the chance of complications as discussed above.

• The flow rate is directly linked to the cannula’s internal diameter and inversely proportional to its length. A cannula with a wide gauge and a short length will result in a quicker flow rate. The flow rate of the cannula can be found on the back of the individual cannula packaging.

Colour Common Applications Size Gauge

Orange Used in theatres or emergency for rapid transfusion of blood or viscous fluids 14G

Grey Used in theatres or emergency for rapid transfusion of blood or viscous fluids 16G

Green Blood transfusions, parenteral nutrition, stem cell harvesting and cell separation, large volume of fluids 18G

Pink Blood transfusions, large volumes of fluids 20G

Blue Blood transfusions, most medications and fluids 22G

Yellow Medications, short term infusions, fragile veins, children 24G


Procedural Competence The cannulation procedure has four separate stages:

• Stage 1 At the patient’s side: obtaining consent and discussing the procedure.

• Stage 2 Gathering and preparing your equipment.

• Stage 3 At the patients’ side: Performing the procedure & after care advice

• Stage 4 Disposal of waste and documentation

Procedure Rationale

Obtaining consent and discussing the procedure with the patient. Obtaining consent

1. Explain to the patient what it is you would like to do. 2. Explain to the patient Why you would like to cannulate them. 3. Explain to the patient How you intend to cannulate them. 4. Discuss the Risks to them that are associated with being

cannulated. 5. Explain: • That a small plastic tube called a cannula will be placed into

one of their veins in order to administer medications or fluids. • That the procedure maybe a little uncomfortable but should

not be painful. • That the procedure involves using a needle to puncture the

skin and vein, which feels like a sharp scratch, the needle is then used to guide the cannula into the vein.

• That once the cannula is in the vein, the needle is fully removed and that he cannula will remain in situ for the treatment and will be checked daily

Explain to the patient the rationale for inserting the cannula, whether it is for the administration of fluids or medications and how long the cannula is likely to remain in situ in order for the patient to give informed consent Once the rationale for the procedure continue the process of gaining consent from the patient. Please refer to the SCH Consent Policy Once all the risks and benefits have been discussed ask the patient if they have any question and confirm that they give you their consent for you to proceed.

Confirmation of identification. Check the following:

• Patients Full Name. • Patients Date of birth. • Patients Hospital / NHS Number.

It is best practice to ask the patient to give their Full Name, Date of Birth and for this to be confirmed against the information on the patient’s wrist band and an official hospital document. It is unlikely the patient will know their own ‘NHS’ Number, so this must be checked against an official hospital document such as the patient’s medical notes.

It is of paramount importance that correct identification of the patient is at the very beginning of any discussion.

Before any procedure on a patient is carried out, it is essential that knowledge of medical history and any previous experiences they may have had, is identified. Consider the following:

• Is the patient left or right handed? By determining and

The information gained at this stage can prove invaluable and may provide the patient with a more positive experience Taking time to talk to patients puts them at ease, reduces anxiety and can


avoiding the patient’s dominant hand may prevent the cannula limiting the patient’s independence whilst in hospital.

• The rationale for insertion may require that a particular medication or volume of fluid should be administered into a large vein.

• Will the site you choose for the cannula prevent the patient from being able to wash or dress themselves? Thereby limiting their ability to care for themselves.

• Is the patient taking any blood thinning medications, or do they have any blood clotting disorders that may mean they are prone to bruising or bleeding for an extended period of time?

• Has the patient been cannulated before and if so were there any difficulties with regard to insertion or post insertion.

• The temperature of the environment may determine whether or not veins are easily palpable.

• Has the patient had Cerebral Vascular Accident or Transient-Ischaemic Attack or any condition that as resulted in a loss of sensation in the arm or hand. In this situation you should avoid the side with the loss of sensation.

• Does the patient have an arterio-venous fistula. If so do not attempt to insert a cannula into the arm with the arterio-venous fistula. It is advisable to seek senior help or discuss with staff based in the local Renal Unit.

• Has the patient ever had any Breast Surgery such as mastectomy or any procedure where the lymph nodes have been removed. The use of a tourniquet and also the potential for infection may result in lymphodema. In this situation it is best to avoid the side where surgery has taken place.

• Elderly patients often have prominent but fragile veins, they may have a loss of subcutaneous tissue supporting their veins and therefore tend to be tortuous and fragile. Care should be taken and the most suitable vein should be chosen using the smallest gauge cannula that is clinically appropriate to minimise trauma.

• Patients who are in shock or who are dehydrated will have poor superficial peripheral access.

• Patients who take steroids or anticoagulants may have fragile veins and be prone to bleeding or bruising after the procedure.

• Patients who are having repeated short term cannula’s inserted are at higher risk of developing phlebitis, these patients will need closer monitoring.

• Patients may have a preference about where you site the cannula however, check both sides for the most clinically appropriate site.

build trust between the healthcare professional, patient and their next of kin.


Risks associated with clinical procedure must be discussed with the patient during the consent taking process. These include:

• Infection of the puncture site. • If the vein is missed on the first attempt, confirm with the

patient that you have their consent to continue cannulating them. A maximum of 2 insertions should be attempted and then ask another colleague to make a further attempt to cannulate.

• Consider why the first attempt was not successful and what can be done to ensure the subsequent attempts are successful. Do not assume that there are a minimum of 2 attempts before asking for assistance from a more experienced colleague.

• Haematoma / Bruising. • Inform the patient that there may be application of pressure

to the area for a longer period of time if the haematoma or bruising is significant, also report to a senior nurse for review.

• Extravasation. • Discuss and explain the signs of tissuing so that the patient

can alert staff if it should occur. • Phlebitis • One possible complication of peripheral IV cannulation is

phlebitis which may be caused by the administration of irritating or vesicant solutions especially if they are administered via a small vein.

• Hit another structure such as; Nerve, Artery, and Bone. • Needle phobia.

It is very important to find out if the patient has a needle phobia. If so, it may be helpful to find out if the patient has any coping mechanisms or how this issue has been dealt with before.

• The application of a topical anaesthetic cream may be helpful; however, this may take some time to work. Asking the patient to look away or distracting them by asking another member of staff to talk to them or reassure them whilst you perform the procedure may be helpful. If the patient has a history of fainting then you should ideally lay the patient on a couch or bed. It would be safe practice to ensure you have sufficient safety equipment and another member of staff available to assist you if this should occur. You must be satisfied that you know how to manage a patient who has fainted before beginning the cannulation attempt.

• Allergies / Sensitivities. • Ask the patient if they have any allergies or sensitivities, in

particular ask the patient if they have any allergies or sensitivities to the specific equipment you are going to use whilst cannulating, such as gloves, adhesive dressings, skin

Remember if they are not aware of the risks then they cannot give informed consent and therefore consent is not valid


cleanser. • If the patient has a confirmed allergy or sensitivity they

should be wearing a RED wrist band, if within the In-patient environment. The substance they are allergic to and the type of reaction they may have, should be fully documented in the medical and or nursing admission notes and on the patients drug chart. It is also good practice that you ask the patient directly if they have any allergies / sensitivities, the information is correct.

• Sharps: please follow the SCH sharps guidance, found within the Infection Control Policy Manual


Appendix 2: Care of Midlines, PICC lines, and Central Catheters Procedure for long term maintenance of all lines This should be completed a minimum of once a week for all PICC and central lines, if not used on a regular use, and needs to be completed prior to any blood samples or infusions, if required.

Equipment Required Notes

Sterile dressing pack 2% Chlorhexidine in 70% Alcohol solution and wipes

Chloraprep and wipes

Stat Lock Bung Steri-strips 6mm x 100mm Transparent dressing x 2 10cm x 12cm Tegaderm range as per SCH Wound Care Formulary. Non-sterile gloves Disposable apron 10ml syringe x 2 Luer lock Blunt filter needle Normal saline 10ml for injection If prescribed ensure GP prescribes “normal saline for

injection not irrigation” Sharps bin

Action Rationale

1. Clean hands and put on apron 2. Prepare sterile field and put on non-

sterile gloves To create a sterile field and prepare site

3. Remove dressing in an upwards motion taking care not to dislodge line

To enable clear viewing of line

4. Note the length of line using the marker dots

To ensure that line is still correctly sited

5. Put on sterile gloves from pack To enable aseptic technique 6. Clean site with Chloraprep using firm

pressure to cleanse all layers of skin cleaning away from exit site and allow to dry. Include cleaning the line itself.

To reduce the risk of cross contamination

7. PICC lines should be laid along the inner aspect of the forearm

To prevent kinking/ damage to line

8. Steri-strip along line; place 1st steri-strip 1cm from exit site and the remaining 4 or 5 along the line

To ensure clear view of line during procedure and to ensure line remains in situ

9. Cover with transparent dressing width ways from above the exit site to the bung

To ensure clear view of line during procedure and to ensure line remains in situ

10. Discard the posiflow bung, clean the end of the line with 2% Chlorhexidine in 70% Alcohol wipe, and allow to dry. Replace with a new posiflow bung.

To reduce any cross contamination or increased risk of infection.

11. Flush line with 10mls normal saline To ensure line is clear, all surface area of the line is


for injection with push pause technique without any disconnection

covered, and the valves in the circulatory system can manage the volume.

12. Clean bung with chlora wipe, and allow to dry.

To check for any indications of infection to enable remedial action

13. If the line has more than one lumen each port will need to be flushed individually.

To maintain patency of all lines

14. Dispose of waste according to SCH policy

To reduce the risk of contamination

15. Document in patient records; paper and SystmOne.

To provide a point of reference or comparison in the event of later queries


Appendix 3: Procedure for taking blood samples from lines

Equipment Required Notes Sterile dressing pack 2% Chlorhexidine in 70% Alcohol solution and wipes Chloraprep and wipes Stat Lock Only if requested Bung Non-sterile gloves Disposable apron 10ml syringe x 2 Luer lock Blunt filter needle Normal saline 10ml for injection If prescribed ensure GP prescribes “normal saline for

injection not irrigation” Sharps bin

Action Rationale 1. Clean surface of trolley or tray as per SCH

policy if used. If no tray or trolley available ensure you have a flat surface available to secure a sterile field.

To reduce the risk of cross infection

2. Wash hands with liquid soap and water if visibly soiled and apply alcohol hand gel.


3. Prepare equipment as above To ensure all equipment is readily available 4. Put on sterile gloves and place sterile field

under line. To enable aseptic technique and maintain asepsis

5. If using a posiflow bung, and it is NOT due to be changed - Clean bung with sterile alcohol solution (2% chlorhexidine in 70% alcohol/ Chloraprep), allow to dry (min 30 secs).

To maintain asepsis and reduce the risk of cross contamination

6. If using a posiflow bung and it IS due to be changed - discard. Apply new Posiflow and leave in situ.

To enable easy removal

7. If blood sample required, draw back and discard 5mls of blood using a 10ml Luer lock syringe.

To ensure a fresh blood sample

8. If blood samples are required, and available, attach multi adaptor and take samples. If no adapter available, withdraw blood using a 10ml syringe. Flush with 10mls Normal Saline for injection post taking samples, using a push/pause technique, and finishing with positive pressure.

For ease of obtaining samples and maintaining patency of line

9. Ensure the end of the line is left clear and free from blood

To reduce the risk of stasis and cross infection

10. Only flush with 10ml Luer lock syringe or bigger.

Smaller syringes can cause an increase in positive pressure and damage/rupture the line.

11. Hickman Line will require as above with the inclusion of Hepsal Flush (10 units per 1ml

Hepsal Flush (10 units per 1ml (50 units in 5ml) or a heparin lock 100 i.u. per ml. 2.5ml is the recommended


(50 units in 5ml). If required as per guidance. and most widely used per lumen. 12. Remember to unclamp and clamp before and

after flushing, if clamps present To maintain patency and safety of line

13. Dispose of all waste according to SCH Policy. To reduce the risk of contamination 14. Document the date and time of the change in

the patient's notes or on SystmOne. To provide a point of reference or comparison in the event of later queries


Appendix 4: Procedure for any infusion/ all lines

Equipment Required Notes Sterile dressing pack 2% Chlorhexidine in 70% Alcohol solution and wipes Chloraprep and wipes Stat Lock Only if requested Bung Non-sterile gloves Disposable apron Giving set 10ml syringe x 2 Luer lock Blunt filter needles Bag of saline to add drug to, if using intermittent infusion

Vol will depend on drug additive

Normal saline 10ml or 50ml bag of saline, if using an intermittent infusion

Only 20mls required

Sharps bin

Action Rationale 1. Prior to setting up, if 1st visit, you will need to

ensure you have worked out your drug calculation and your drop rate, and documented this within the care plan. After the 1st visit, this calculation should be checked weekly.

2. Clean surface of trolley or tray as per SCH policy if used. If no tray or trolley is available, ensure you have a flat surface available to secure a sterile field.


3. Wash hands with liquid soap and water if visibly soiled and apply alcohol hand gel.


4. Prepare equipment as above, including your infusion, using an ANTT approach.

To ensure all equipment is readily available

5. Put on sterile gloves and place sterile field under line.

To enable aseptic technique and maintain asepsis

6. If using a posiflow bung, Clean bung with sterile alcohol solution (2% chlorhexidine in 70% alcohol/ Chloraprep), and allow to dry (min 30 secs).

To maintain asepsis and reduce the risk of cross contamination

7. Any weekly maintenance should be performed prior to the infusion.

8. You do NOT need to aspirate, however, if clinically indicated, then aspirate using a 10ml syringe, until blood can be seen within the line. Following the SAS approach, flush line with 10mls saline, in a 10ml syringe, using a push/pause technique.


9. Clean bung with sterile alcohol solution (2% chlorhexidine in 70% alcohol/ Chloraprep), allow to dry (min 30 secs).

10. Attach pre-prepared infusion. If bolus infusion, deliver slowly over recommended time using the push/pause technique. If intermittent infusion, required using a giving set, deliver over drop rate, as previously calculated.

11. Whilst infusion running, monitor for any signs of anaphylaxis, if any signs occur, stop the infusion and monitor patient.

12. When infusion has finished: If bolus, clean bung with sterile alcohol solution and allow to dry, then flush with 10ml saline, using a 10ml syringe, using the push/pause technique, finishing with positive pressure. If using an intermittent infusion, attach 50ml bag of saline to giving set, ensuring the ANTT is maintained, and run a minimum of half the bag through on a slow drop rate.

The saline flush does NOT need to be prescribed. Do NOT use any syringe smaller than 10mls

13. Disconnect the giving set, clean the bung with sterile alcohol solution and allow to dry. If any further infusions are required, then repeat the process for each infusion.

14. Hickman Line will require as above with the inclusion of Hepsal Flush (10 units per 1ml (50 units in 5ml). If required as per guidance.

Hepsal Flush (10 units per 1ml (50 units in 5ml) or a heparin lock 100 i.u. per ml. 2.5ml is the recommended and most widely used per lumen.

15. Remember to unclamp and clamp before and after flushing, if clamps present

To maintain patency and safety of line

16. Dispose of all waste according to SCH Policy. To reduce the risk of contamination 17. Document the date and time of the change in

the patient's notes or on SystmOne. To provide a point of reference or comparison in the event of later queries


Appendix 5: Guidelines for Sub-Cutaneous fluids Subcutaneous infusion is indicated for maintaining:

• Adequate short term hydration, in service users, who are unable to take adequate fluids orally. • Who are mildly to moderately dehydrated. • Whom it is difficult, or impractical to insert an intravenous (IV) line.

Subcutaneous infusion should only be considered in situations where:

• There is acute inadequate oral intake, e.g. service users with dysphagia or cognitive impairment or in terminal care.

• The service user is distressed by symptoms of dehydration such as weakness, postural hypotension or thirst.

Recommended fluids for infusion:

• Sodium Chloride: 0.9% or 0.45% (most common). • Dextrose Saline: 2.5% glucose, 0.45% sodium chloride.

Additives

• Registered Nurse must not add any medications to bags of fluid for subcutaneous infusion, unless specifically prescribed.

Recommended Infusion Rates • Usual rate only 1 ml per minute per site. • Maximum of 1.5 litres in 24 hours using a single site or 3 litres in 24 hours if using 2 sites. • Two infusion sites may be used if more than 1 litre in 24 hours is required (Bruera et al 1996; Ferrand &

Campbell 1996). • Subcutaneous fluids should only be infused via gravity using a standard IV giving set connected to a

long tube butterfly needle via luer lock connections. The subcutaneous infusion should be sited in a position with good lymphatic drainage to maximise absorption. Such sites include:

• Inner thigh. • Anterior chest wall, below the clavicle (caution should be exercised when using this site in cachectic

service users). • Lateral abdominal wall. • Back, usually below the shoulder blade (useful in confused service users). • Lower limb sites should be avoided in ambulatory service users because blood may backflow into the

line and block cannula.


Equipment Required

Notes

Solution for infusion See (8.3) Selection of Fluids and Rate of Infusion in guidance notes.

Giving set with drip chamber Check drip per ml rate on packaging

Long tube butterfly needle (21-25 gauge) or a Softset plastic infusion set

70% Isopropyl alcohol swabs

Sterile occlusive dressing and gauze

If available, a suitable stand or hook to allow solution bag to be hung higher than the level of the service user

Sterile gloves and sharps bin

Action Rationale

Document all batch numbers and serial numbers prior to starting infusion.

To ensure they are available in case of any adverse incident

Check solution bag for contaminants and ensure sterile packaging is intact.

To ensure fluids are fit for administration

Prepare all equipment using aseptic technique. To ensure there is no contamination of equipment

Connect up giving set to subcutaneous infusion needle set. To ensure the correct equipment is used Pierce infusion bag port, with giving set and prime entire length of tubing with solution.

Select infusion site, taking into account service user choice and the guidance notes on Selection of Sites.

To ensure the optimum site for infusion is selected

Prepare site with alcohol swabs. Begin at site centre and spiral outwards, allowing 30-60 seconds contact time and allow to dry.

To ensure site is clean

Insert the infusion needle into the skin at an angle of 45o (for winged infusion sets) and support the butterfly at the correct angle with a small piece of gauze if required. Softset infusion devices should be inserted at a 90o angle by grasping a fold of skin and inserting the needle to its full length so that the device is flush with the skin.

To ensure correct placement of the line

Create a loop in the tubing around the needle site to avoid the needle from being pulled out if giving set is inadvertently pulled.

To secure line in place

Secure needle and loop against the skin with a sterile occlusive dressing.

To ensure line remains safely in situ

Document in patient care plan as per SCH Record Keeping Policy

To provide a point of reference or comparison in the event of later queries


Changing site and giving set

• The length of time a site can be used can vary from 1 to 14 days (Kain et al. 2006).

• No clinical evidence exists to recommend exactly how often the site and giving set should be changed.

• Anecdotal and case study evidence exists to suggest that changing the infusion site and giving set every 48 – 72 hours is safe practice (Abdullah & Keast, 1997; Macmillan et al, 1994; Yap, 2001).

• However caution should be taken not to exceed the maximum lifespan recommended by the manufacturer of the particular device so that their product liability can be maintained.

• The site must be checked at least daily to look for signs of redness, induration, tenderness, bleeding, oedema or leaking and documented.

• The site must be changed when required regardless of its duration if any of these complications are observed.

• When the site is changed the giving set must be changed at the same time.

• Sites should be rotated to minimise tissue damage.

Checking the site

• The site must be checked within 30 minutes of insertion to assess skin integrity and to avoid tissue overload.

• Once hypodermoclysis is established the service user or carer should be educated about checking the infusion at agreed intervals and this should be clearly documented in patient’s notes.

• The patient or carer should be shown how to stop the infusion if any adverse reactions occur and to contact the district nursing team if any concerns arise.


Appendix 6: Care, Maintenance and Access via a PORT-A-CATH. A Port -a -Cath is a Totally Implantable Venous Access Device (TIVAD) used for some patients who need repeated long term intravenous drug therapy. In appropriate circumstances patients or their carers can be trained, under instruction from appropriately trained staff to use the system for administering antibiotics in the home (Cochrane Library 2010). A Port-a-Cath may be in place for several years so it is important to take into consideration the patient lifestyle, work activities before insertion (Goodwin and Carlson 1993). The most common veins for insertion of a Port-a-Cath are the Subclavian, Internal or External Jugular Veins, Cephalic or Femoral Veins. SystmOne SystmOne will prompt the practitioner to complete:

• VIP score • Size of Gripper needle • Number of attempts and any problems with attempts • Time of removal • Procedure used to remove Gripper needle • Any complications • Integrity of Venous Access Devise • Appearance of site • Type of dressing used • Patients response to removal


Appendix 6a: Procedure for accessing and maintenance flushing of a PORT-A-CATH. At all times, staff must adhere to their codes of professional conduct (Nursing Midwifery Council (NMC) 2008). The patient may feel a pricking sensation as you insert the Gripper needle, if the patient feels this is uncomfortable a local anaesthetic may be used to temporarily numb the skin. This sensation will decrease over time. Equipment for maintenance flushing of a Port-a-Cath:

• Dressing Packs • Sterile Gloves • 10ml syringe • 2x10ml Luer lock syringes with 0.9% Saline • 2% Chlorhexidine Gluconate in 70% Isopropyl alcohol to clean skin • 2% Chlorhexidine Gluconate in 70% Isopropyl alcohol wipe per lumen • Sterile bung of choice • If required - Blood /culture sample bottles, vacutainers with blue access device (if required) • 20/22g ¾ inch Gripper Needle* • 1 x Green hypodermic needle • 10ml Sodium Chloride 0.9% for injection • Heparin Sodium flushing solution (200iu/2ml) will require a prescription • Occlusive dressing • Sharps box

* For newly inserted devices a larger Gripper needle may be needed due to localised swelling 2% Chlorhexidine Gluconate in 70% Isopropyl alcohol is the solution of choice. However, in the case of patient sensitivity providone-iodine is to be used. A Port-a-Cath must be flushed monthly if not in regular use. Use heparinised saline which must be prescribed (200iu/2ml). Types of PORT-A-CATH flush/volume/locking solution and frequency Type of line Type of

flush/lock required

Volume of Flush Volume of Locking Solution

Frequency

Port-a-Cath (open-ended)

0.9% Sodium Chloride for Injection and Heparin solution 100iu/ml

Flush with 10-20ml 0.9% Sodium Chloride for injection

Lock with 2ml Heparin solution

Flush lumens following fluids/drug administration or blood sampling. If not in regular use flush with 10ml 0.9% sodium chloride for injection at least daily. Locking is only required on removal of Gripper needle. Access, flush and lock monthly.

Port-a-Cath (valve-Bard)

0.9% sodium chloride for injection

Flush with 10ml 0.9% sodium chloride for injection

Not required Flush lumens following fluids/drug administration or blood sampling. If not in regular use flush with 10ml 0.9% sodium chloride for injection at least daily. Access and flush monthly when not in use.


Appendix 6b: Procedure for maintenance flushing of a PORT-A- CATH NB. This procedure is for maintenance flushing of Port-a-Cath. If the needle is to remain in for ongoing treatment please refer to the procedure to allow access for intravenous therapy below. This is an aseptic non-touch technique (ANTT) Dual lumen ports – caring for a double or dual lumen port is the same as caring for a single lumen port. At times both portal chambers may be accessed simultaneously. Both lumens should be flushed after an infusion or every four weeks when not in use. PRINCIPLE RATIONALE

1 A. Identify patient as per SCH guidelines.

B. Explain and discuss the procedure to the patient and gain verbal consent for care. C. Check signed drug administration chart and correct medications are available D. Ensure patient understands procedure.

To ensure the patient understands the procedure and gives their valid consent.

2 Assist patient into a suitable position, supine or sitting in chair.

For patient comfort and ease of access

3 Ascertain that the patient has had no pain or discomfort with the Port-a-Cath before palpating the position of the portal. If pain or swelling present seek expert advice.

Pain may indicate infection or dislodgement of the Port-a- Cath. Referral for line-a-gram may be required.

4 Check with patient where Port-a-Cath is sited and locate port by palpation. Review signs of infection and seek medical advice if required.

Port-a- Caths may be sited in various sites e.g. chest wall, mid-axillarie line, arms.

5. Wash hands, open packs onto appropriate dressing area/trolley, place equipment on sterile field decontaminate hands with alcohol gel and put on sterile gloves. This is a sterile procedure.

To minimize the risk of infection

6.

Clean skin with, 2% Chlorhexidine in 70% alcohol solution starting at the portal and working outwards in a spiral motion to at least 8cm over 30 seconds. Allow to dry.

To minimize the risk of infection

7. Prime the Huber point (non-coring) “Gripper” needle and extension tubing with, 2-3mls of 0.9% sodium chloride. Leave the syringe attached but close the clamp on the extension tube.

To prevent air entry. To ensure needle is patent. To prevent backflow of blood when Port-a-Cath is accessed.


8. Locate the dressing field close to the Port-a-Cath. Relocate and stabilize the portal by placing first and middle fingers of non-dominant hand either side of the Port-a-Cath.

To provide a sterile area to rest the attached syringe. To prevent the Port-a-Cath from moving when the needle is inserted.

9. Push the Huber non-coring needle at a 90 degree angle to the Port-a-Cath firmly through the skin and the silicone septum until the needle touches the metal at the back of the Port-a-Cath, as illustrated below. NB This can often be felt as a Tap.

To gain access to the Port-a-Cath.

10. Open clamp and after checking for flashback of blood to confirm patency, slowly inject sodium chloride, adopting a pulsating motion to create turbulence within the line. Ask the patient if they experience any pain on flushing. Observe the site for any swelling.

To flush the Port-a-Cath and maintain patency. Correct flushing technique contributes significantly to the preservation of line patency. Pain and /or swelling could indicate a misplaced needle or other complication. If this occurs the patient must be referred to the nearest acute unit for assessment.

11. Assess patency of Port-a- Cath whilst injecting sodium chloride.

If the needle is correctly placed and the Port-a-Cath is patent, there should be little resistance.

11a. If resistance is felt check that the needle is located correctly and is touching the back of the Port-a-Cath and you have released the clamp.

If the needle is not touching the back of the Port-a-Cath the silicone septum will block the hole in the side of the needle

11b. If the needle is thought to be correctly located and resistance is still felt, seek expert advice.

A partially or fully blocked Port-a-Cath will need further investigation so that appropriate treatment can be Commenced.

11c. If there is any doubt that the needle is incorrectly sited, it may be necessary to remove the needle and site a new one.

A misplaced needle will result in pain and resistance when flushing.

12. Apply positive pressure on the syringe plunger before closing the clamp. Close clamp and remove syringe.

To prevent backflow of blood and air entry to the line.


13. Attach syringe containing prescribed heparin sodium, open clamp, inject heparinised sodium and close clamp using positive pressure prior to clamping.

To prevent flow of blood in the line which may result in line blockage.

14. Relocate and stabilize the Port-a-Cath by placing first and middle fingers of non-dominant hand either side of it and gently but firmly pull the needle out.

To prevent the movement of the Port-a-Cath on withdrawal of the needle.

15. Repeat flushing of Port-a-Cath every 4 (RCN 2010; Weinstein 2007).


Appendix 6c: Procedure to allow access to a PORT-A-CATH for intravenous therapy Equipment required allowing access to a Port-a-Cath for intravenous Therapy:

• Dressing Packs • Sterile Gloves • 10ml syringe • 2x10ml Luer lock syringes • 1 Blunt fill needle with filter • Bionector or suitable needle-less bung • 2% Chlorhexidine Gluconate in 70% Isopropyl alcohol to clean skin • 2% Chlorhexidine Gluconate in 70% Isopropyl alcohol wipe per lumen • Sterile bung of choice • If required - Blood /culture sample bottles, vacutainers with blue access device (if required) • 20/22g ¾ inch Huber point “Gripper” Needle (L shaped needle) • 1 x Green hypodermic needle • 10ml Sodium Chloride 0.9% for injection • Heparin Sodium flushing solution (200iu/2ml) will require a prescription • Occlusive dressing • Sharps box

Action Rationale 1 Follow procedure for flushing numbers 1 –

13. To access Port-a-Cath.

2 Attach bionector bung. To allow needleless access 3 Remove the white plastic gripper top from

the Huber needle. To support the needle and to prevent the needle fracturing. To provide patient comfort

4 Apply a 3cm x 3cm square of gauze over the needle area and the transparent semipermeable dressing over the top ensuring the whole area is sealed and the extension line is not causing pressure on patient’s skin. (DOH 2010)

To enable dressing to be changed without dislodging needle. To support needle and allow for showering and bathing. To prevent pressure degrading skin integrity.

5 Discard used equipment according to hospital policy

Protection of patient, staff and environment

6 Document needle size used

To ensure appropriate selection on subsequent


Appendix 6d: Procedure for taking a blood sample from a PORT-A-CATH To prolong the life span of a Port-a-Cath it should ideally never be accessed purely for blood sampling. Routine blood sampling should be planned where the Port-a-Cath is accessed for flushing or IV Therapy. If a patient has had problems with a blocked or partially blocked Port-a-Cath it is be advisable to take blood samples via an alternative route. Difficulty may be encountered when taking blood samples. One of the causes is that the tip of the soft catheter lies against the wall of the vessel and the suction required to draw blood brings this into close contact, leading to temporary occlusion. There could also be a collapse of the catheter walls when using the vacuum system which may necessitate the use of syringes to obtain the blood. Measures to dislodge the tip include asking the patient to: Trouble Shooting: 1. Cough and breathe deeply 2. Lie patient down 3. Roll from side to side 4. Raise his/her arms 5. Perform the Valsalva manoeuvre, if possible 6. Increase general activity, e.g. walk up and down stairs. (Gorski, Perucca and Hunter 2010; Moureau 1999) Obtaining blood samples from a Port-a-Cath can lead to inaccurate results, especially coagulation and antibiotic assays (Frey 2003). The discard method is the standard accepted method (Homes 1998). This ensures removal of any heparin or saline solution. (See following procedure) This procedure needs to be undertaken in a timely fashion if the blood does not flow freely into the bottles then the procedure must be abandoned as delay may risk blood clotting in the Port-a-Cath potentially necessitating its removal. Equipment required allowing blood sampling from a Port-a-Cath:

• Alcohol gel - hand wash solution • Sterile Dressing pack • Sterile gloves of appropriate size • 1 x Sani-Cloth CHG 2% - for disinfection of hubs and connection ports • Luer lock syringe – 10ml x 2 • 1 Blunt Filler needle with Filter • 2 green hypodermic needles • 2 x 10ml Sodium chloride 0.9% for injection • vacutainers system adaptor for blood sampling • Vacutainers system container holder (shell) • Heparin Sodium as prescribed • Huber non-coring ‘Gripper’ needle of correct gauge and length • Bionector or suitable needleless bung

Vacuum system Blood specimen bottles correctly labelled as per policy ensuring expiry dates on the bottles are checked.


ACTION RATIONALE

1. Perform procedure using sterile technique.

Wash hands with bacterial soap and water or alcohol gel as per trust policy.

To reduce risk of infection and contamination of blood samples obtained.

2. Prepare tray or trolley and take to patient. Clean hands as above and open sterile pack and equipment.

To reduce risk of contamination of contents.

3. Clean hands with alcohol hand rub. Put on sterile gloves and using gauze from dressing pack, remove bung. Clean end of catheter line with alcohol wipe and allow drying.

To minimize risk of introducing infection. To prevent contamination of practitioner’s hands with blood.

4. Attach syringe immediately withdrawing 5ml blood and discard. If unable to withdraw blood try flushing with 1-2mls of sodium chloride. Check needle placement and then draw back. Verifying placement by pushing on the needle until it hits the base of the port. If still unable to drawback, change patients position, getting them to look upwards and away from the port. If still unable to obtain blood, seek advice, do not keep accessing port. Once old blood has been discarded take blood samples.

To enable disinfection process to be completed. To prevent contamination of blood Sample syringe.

5. If taking blood samples using an empty syringe, remove blood required. If vacutainers system is to be used attach adapter to the line and twist blood bottle on, release the clamp, attach the required vacutainers blood specimen bottles to obtain the required amount of blood under vacuum, close the clamp and disconnect the vacutainers in a timely fashion.

To obtain required volume of blood for sampling. Order of samples: 1. Cultures 5ml each bottle (if needed) 2. Clotting screens (Blue) 3. (Yellow/Gold) – LFT/U&E/CRP/TFT/ (Vit ADEK photosensitive) 4. EDTA (Purple) FBC/ESR/HbA1c/ 5. Fluoride Oxalate (Grey) Glucose It is important to complete this task as soon as possible to prevent blood clotting in the line.

6. Attach 10ml luer lock syringe, open the clamp and inject 10ml 0.9% sodium chloride adopting a pulsating motion to create turbulence within the line. Close the clamp and discard syringe.

To flush blood from line.

7. Attach the 5mls heparin sodium (Hepsal or Hepflush, or Heplock) as prescribed syringe, open the clamp and inject, adopting a pulsating motion to create turbulence within the line, clamp line whilst using positive

To maintain patency and positive pressure in the line, needle and extension set.


pressure technique, and discard the syringe.

8. If Gripper needle to remain insitu, flush with Hepsal and clamp under positive pressure while injecting the last 1ml of Hepsal.

To ensure patency of line.

9. Fit new /sterile bionector, secure with appropriate dressing.

To prevent air entry, infection and allow needleless access.

10. If Gripper needle to come out, flush with normal Saline and remove set whilst injecting the last 1ml of Heprin lock, then remove infusion set.


Appendix 6e: Procedure to administer intravenous medications via an accessed PORT-A-CATH The administration of medications and solutions shall be initiated upon the order of a doctor or an authorized nurse prescriber or as part of a patient group direction (NMC 2008a). Equipment required for administering intravenous medication via an accessed Port-a-Cath:

• Long Extension line with filter • 1 x Sani-Cloth CHG 2% - for disinfection of Hubs and connection ports • This is an Aseptic Non-touch Technique (ANTT)

ACTION RATIONALE

1. Identify correct patient

To Minimize drug errors

2. Check prescription chart according to the local drug administration policy to ascertain type of medication and correct dosage needed. Check drug and expiry date.

To ensure drug is given as prescribed, at the correct time, therefore minimizing errors.

3. Prepare drugs as per local intravenous therapy Guidelines.

To ensure drugs are prepared and checked correctly.

4. Take prepared drugs to patient. 5. Wash hands or use alcohol gel hand rub as per

hospital policy.

To reduce risk of infection.

6. Clean bionector using the Sani-Cloth alcohol wipe. Allow to dry.

To prevent introduction of bacteria

7. Attach syringe containing 10ml 0.9% sodium chloride to bionector using clockwise ¼ turn to lock syringe in place. Open clamp, inject using positive pressure technique, and observe for any swelling around Port-a-Cath site. Ask patient if they feel any pain.

To check patency of Port-a-Cath. Swelling can indicate extravasation. Pain can indicate complications.

8. Clamp catheter, remove empty syringe and connect syringe containing 1st intravenous medication to bionector – via extension line, secure syringe in Omnifuse pump and commence infusion.

To provide positive pressure during infusion time.

9. On completion of infusion, clamp extension line above and below bionector, remove empty syringe and attach syringe containing 10ml 0.9%, to extension line ensuring ANTT is adopted, unclamp both clamps, inject using positive pressure technique.

To flush catheter, to remove residual medication and prevent problems from incompatibility. To minimize risk of bacterial contamination.


10. Clamp both clamps, remove empty syringe, discard and attach 2nd medication syringe, unclamp both clamps and recommence infusion.

To prevent reflux of blood into line.

11. Clamp both clamps, remove and discard empty medication syringe.


12. Attach final syringe containing10ml 0.9% sodium chloride, unclamp both clamps, inject using positive pressure technique, clamp.


13. Remove empty syringe and discard.


Appendix 6f: Procedure guideline for unblocking a PORT A CATH occlusion

• Catheters may become occluded for a number of reasons, e.g. not being flushed adequately or using the incorrect flushing technique, infusion being switch off or running too slowly or recipitation formation due to inadequate flushing between solutions/drugs.

• Clearance of a catheter occlusion is best performed using a negative pressure approach. The establishment of negative pressure within a catheter means creating a vacuum by aspiration of the air or ‘dead space’ within a catheter (Moureau 1999; Dougherty 2006; Gabriel 2008).

• Unblocking a catheter is not a quick procedure and can take up to 30 minutes to achieve success. Seek specialist nurse / medical advice if the line is patency is not easily achieved. For the management of complete occlusion it is essential to contact the patient’s Acute Clinician for guidance.

Management of partial PORT A CATH occlusion


Troubleshooting A Port-a-Cath may become blocked for several reasons; immediate action is necessary to successfully restore patency:

• Incorrect or infrequent flushing technique, infusion being switched off or running too slowly or precipitation formation due to inadequate flushing between solutions/drugs.

• Build-up of crystallized drug or ‘sludge’ in the Port-a-Cath chamber. This is often characterized by gradual build-up of resistance when flushing. It may be improved by more frequent flushes (e.g. every 2 weeks).

• Formation of blood clot at the catheter tip. This is often characterized by sudden catheter occlusion when previous flushes have shown no resistance.

• Catheter rupture-usually there is sudden occlusion and this may be associated with pain or swelling.

• Patient complaining of swelling in hands/neck/face indicating that the catheter tip has moved.

Points to check:

• Check that all clamps are open when attempting flush.

• Ensure that the needle is sited correctly.

• Is the needle pushed down far enough into the Port-a-Cath?

• Re-needle if necessary.

• Is there any inflammation at the Huber needle insertion site?

• Does the patient have any pain?

• Seek expert/medical advice.

• Immediate referral to registered nurse or doctor with advanced knowledge in management of Port-a-Cath devices is appropriate if you still have concerns.


EQUALITY IMPACT ASSESSMENT FORM

Title of Guideline: IV Therapy and Sub-Cutaneous Infusion Policy Description: Suffolk Community Healthcare requires that registered nurses have the knowledge, skill and competence required should they care for and administer drugs to a patient via any centrally inserted and other lines. Part 1: Assessment of Impact a) How will the policy meet the needs of different communities and groups? • Age – This guideline applies to adults only. Within

this group, it is not considered that the age will have any impact on the application of this policy

• Religion or Belief – This organisation is aware of different religions and belief systems & is mindful of ethnic sensitivities relating to certain procedures but this guideline is considered to apply equally to all groups

• Disability – It is anticipated that this guideline will impact on all adult patients in equal measure

• Sexual Orientation – It is considered that this guideline should apply equally to all patients whatever their sexual orientation

• Ethnicity – This organisation is aware of different practices and different ethnic groups but this guideline is considered to meet the needs all such groups

• Socio-economic disadvantage – This guideline should not impact to cause any socio-economic disadvantage

• Gender (including transgender) – this guideline is intended to meet the needs of all such groups regardless of gender.

• People living in rural areas – This guideline should be applied equally regardless of place of residence and should not impact on people living in rural areas

Other: This organisation recognises that some members of society generally have difficulty accessing health services such as people who are homeless, prisoners or street workers. It also recognises that some patients may be more vulnerable in relation to procedures outlined within this document. However, this guideline should be applied equally to all as it relates to staff competencies the care of centrally inserted lines. b) Positive Impact: Reducing Inequalities: How is the Policy likely to have a significant positive impact on equality by reducing inequalities that already exist? Explain how it will meet our duty to: • Promote equal opportunities: this guideline will

ensure that all staff are equally aware of the correct procedure so that adherence to the guideline is standardised through all patient groups.

• Promote good community relations – As with other policies and guidelines within the organisation, this one aims to ensure that SCH provides quality services to the community of Suffolk ensuring that the whole community has access to a safe healthcare environment. Fostering good relations with partner organisations will be enhance by the


application of this policy. • Get rid of discrimination: staff working within this

guideline and within professional guidelines should avoid discrimination at any level.

• Promote positive attitudes towards, encourage participation in and enable more favourable treatment of, disabled people: This guideline applies to all patients equally irrespective of any disability and staff will make all reasonable adjustments to accommodate any disability.

• Get rid of harassment: There are policies in place which prevent harassment both within the organisation and between the staff and patients (e.g. Whistle Blowing Policy, Disciplinary Policy, Adverse Incidents, Code of Conduct, Confidentiality Code of Practice

• Promote and protect human rights: SCH recognises that patients to whom this guideline applies are potentially vulnerable but this guideline is designed to ensure their human rights are not affected in any way

c) Negative Impact – Potential Discrimination: Could the Policy have a significant impact on equality in relation to each of the following groups or characteristics? • Age – Within the defined age group it in

anticipated that age will not have a negative impact on this guideline.

• Religion or Belief – Staff are expected to be aware of the possibility of differing views by religious groups but this should not impact on the application of the guideline.

• Disability – This guideline should be applied equally regardless of any disability

• Sexual Orientation – This guideline will apply equally regardless of sexual orientation.

• Ethnicity – It is not considered that ethnicity will have a negative impact on this guideline although the attitudes towards it may vary according to ethnic group.

• Socio-economic groups – It is not anticipated that this guideline will have a negative impact in relation to this.

• Gender (including transgender) – This guideline will be applied equally regardless of gender.

• People living in rural areas – It is not anticipated that this will have a negative impact.

Other: This organisation recognises that some members of society generally have difficulty accessing health services such as people who are homeless, prisoners or street workers and/ or more vulnerable. However, this guideline relates to all staff competency in to staff competencies the care of centrally inserted lines and as such will be applied equally and should not have a negative impact. Part 2: Evidence What is the evidence for your answers above? • Age – It is the intention and aims of this guideline

that in consultation with statutory and non-statutory bodies that the policy reflects current best evidence and practice and will be applied equally regardless of the age of the recipient within the defined age-group.

• Religion or Belief - It is the intention and aim of this guideline that it shall be applied equally according to best practice and not discriminate unfairly based on religion or belief.

• Disability – It is the intention and aim of this guideline that it will reflect best evidence based practice and not discriminate based on a physical or mental disability

• Sexual Orientation - It is the intention and aim of this guideline that it shall be applied equally according to best practice and not discriminate unfairly based on sexual orientation.

• Ethnicity – It is the intention and aim of this guideline that it shall be applied equally according

• Socio-economic groups - It is the intention and aim of this guideline that it shall be applied equally


to best practice and not discriminate unfairly based on ethnicity.

according to best practice and not discriminate unfairly based on socio-economic status

• Gender (including transgender) - It is the intention and aim of this guideline that it shall be applied equally according to best practice and not discriminate unfairly based on gender.

• People living in rural areas - It is the intention and aim of this guideline that it shall be applied equally according to best practice and not discriminate unfairly based on ethnicity.

Other: This organisation recognises that some members of society generally have difficulty accessing health services such as people who are homeless, prisoners or street workers. The organisation also acknowledges the increased vulnerability of certain individuals & groups within society in relation t to staff competencies the care of centrally inserted line so this guideline. However, this guideline applies to all staff competencies in IV drug administration and therefore will be applied equally and reviewed regularly to ensure it adheres to current best evidence based practice. Training around equality & diversity issues are also mandatory annually within SCH. Part 3: Conclusion B – A negative impact in unlikely. The guideline has the clear potential to have a positive impact by reducing and removing barriers and inequalities that currently exist. Part 4: Next Action Plan: To review the operation of the policy as per SCH protocol to ensure there are no changes in its impact. Part 5: For the Record Name and Title of people who carried out the EIA: Sarah Miller/ Kim Keable

Name of Director who signed EIA: Pamela Chappell

Date EIA completed: 8/12/14

Signature of Director:


Documents

IV MEDICATION MANAGEMENT AND SUB …...peripheral lines, and sub-cutaneous fluids, in the community once they have been inserted. 1.3 In order for trained nurses to be able to complete