PERIPHERAL CANNULATION€¦ · The term peripheral cannulation refers to the insertion of a cannula into a vein to allow administration of intravenous drugs and fluids. The most common

Page 1 of 35

COMMUNITY SERVICES DIVISION CLINICAL POLICY

DOCUMENT

PERIPHERAL CANNULATION

Policy Number: 102 Scope of this Document: Trained Nurses within the IV

Team and Nurses with Special Interest

Recommending Committee: IV Team Approving Committee: Clinical Standards Group Date Ratified: December 2018 Next Review Date (by): December 2020 Version Number: Version 3 – 2018 Lead Executive Director: Executive Director of Nursing

and Operations Lead Author(s): IV Team

COMMUNITY SERVICES DIVISION CLINICAL POLICY

DOCUMENT

2018 – Version 3

Striving for perfect care and a just culture

Policy on Peripheral Cannulation V3 December 2018

Page 2 of 35

COMMUNITY SERVICES DIVISION CLINICAL POLICY DOCUMENT

PERIPHERAL CANNULATION Further information about this document:

Document name Peripheral Cannualtion (102)

Document summary To provide guidance to Mersey Care Community Health staff undertaking peripheral cannulation

Author(s)

Contact(s) for further information about this

document

IV Team

Published by

Copies of this document are available from the Author(s)

and via the trust’s website

Mersey Care NHS Foundation Trust V7 Building

Kings Business Park Prescot

Merseyside L34 1PJ

Trust’s Website www.merseycare.nhs.uk

To be read in conjunction with

IC01 – Infection Prevention and Control Policy SD44 – Nutrition and Hydration Policy 54 – Blood Platelet Transfusion Policy

32 – Cold Chain Policy This document can be made available in a range of alternative formats including

various languages, large print and braille etc

Copyright © Mersey Care NHS Trust, 2015. All Rights Reserved

Version Control:

Version History: Version 3 Ratified by Clinical Standards Group Dec-18

Version 3

Transferred to Mersey Care NHS Foundation Trust Template, with reference to Liverpool Community

Health NHS Trust replaced with Mersey Care name and branding

6 Jun-19


http://www.merseycare.nhs.uk/

Page 3 of 35

SUPPORTING STATEMENTS

this document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESS

All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: • being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or

by professional judgement made as a result of information gathered about the child / adult; • knowing how to deal with a disclosure or allegation of child /adult abuse; • undertaking training as appropriate for their role and keeping themselves updated; • being aware of and following the local policies and procedures they need to follow if they have a child

/ adult concern; • ensuring appropriate advice and support is accessed either from managers, Safeguarding

Ambassadors or the trust’s safeguarding team; • participating in multi-agency working to safeguard the child or adult (if appropriate to your role); • ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to

Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;

• ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

EQUALITY AND HUMAN RIGHTS

Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.

The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy


Page 4 of 35


Page 5 of 35

1. Introduction

The term peripheral cannulation refers to the insertion of a cannula into a vein to allow administration of intravenous drugs and fluids. The most common way to cannulate a peripheral vein is a ‘cannula over a needle’, where the lumen of a plastic cannula contains a needle that allows insertion through the skin. Once introduced, the needle is removed leaving the cannula in the vein.

1.1 Status

This is a clinical policy for use in Mersey Care NHS Foundation Trust.

1.2 Purpose of the policy

Infusion therapy is provided for patients of Mersey Care NHS Foundation Trust by registered health care professionals. Standard techniques are required to prevent complications like catheter site and blood stream infection, misplacement at point of insertion and dysfunction and loss of patency during insertion.

The purpose of this policy is to ensure a consistently high standard of practice across the trust with regards to peripheral cannulation.

1.3 Scope of Policy This policy applies to staff employed by Mersey Care NHS Foundation Trust undertaking cannulation. This procedure should only be carried out by professionally registered clinical staff.

2. General Policy Statement

Mersey Care NHS Foundation Trust has developed this policy to ensure that staff are trained and equipped properly to effectively approach and improve cannulation technique, ultimately preventing needless cannulation on patients and needless line related infections.


Page 6 of 35

3. Definitions

1

Cannula

Flexible tube/catheter containing a needle, which may be inserted into a blood vessel (Anderson and Anderson 1995)

2

Peripheral catheter

A catheter inserted through the skin

3

Midline catheter

A longer (approx 20 cm) catheter inserted peripherally into a vein on the arm. It is used for mid term infusion of fluids/nutrition

4

Peripheral intravenous central catheter (PICC)

A central venous catheter inserted peripherally into the arm.

5

Central Line A central venous catheter inserted into a large vein in the neck, chest or groin

6

Erythema

Redness of skin along the vein track due to vascular irritation or capillary congestion of fluid; it may be a precursor to phlebitis (Perdue 2001).

7

Phlebitis Inflammation of the intima of the vein (Perdue 2001)

8

Haematoma

Uncontrolled bleeding at a venepuncture site usually creating a hard painful swelling filled with infiltrated blood (Perdue 2001)

9

Infiltration

Inadvertent administration of solution into the surrounding tissue instead of into the intended vascular pathway (Perdue 2001)


Page 7 of 35

10

Saline flush

0.9% sodium chloride for injection to flush the cannula NB It should be prescribed on the drug chart and given by a competent


Page 8 of 35

health practitioner

11

VIIAD

Visual inspection infusion access device indicator

12

Ward Manager

Nurse in charge of a ward in a hospital

Team Leader

Nurse in charge of a team, specifically outlined in this document a team in the community.

13

Service Manager

Manager responsible for services and the staff that deliver them. This is specific to the Manager of the in- patient units and Intravenous Therapy Team Leader.

14

Health Care Professionals

(HCP)

Staff who work within the PCT who have received training in the insertion of peripheral cannula and saline flush

15

Secondary care

The acute hospital setting.

4. Legal and Statutory Duties and Responsibilities

The following general (statutory) duties apply:

All Mersey Care NHS Foundation Trust staff are responsible for co- operating with the development of Mersey Care NHS Foundation Trust policies as part of their normal duties and responsibilities.

All other personnel are expected to comply with the requirements of all relevant Mersey Care NHS Foundation Trust policies applicable to their area of operation.

All potential adverse incidents should be reported in line with the Mersey Care NHS Foundation Trust Accident and Incident Reporting and Management Policy (including serious untoward incidents).


Page 10 of 35


Page 10 of

5. Process

In this document, the process for peripheral cannulation includes:

• Outline of the responsibilities of the accountable practitioners • Patient selection method i.e. indication for use. • Operative procedure of the cannulation, e.g. insertion, management

etc. • Monitoring and documentation method

5.1 Accountable Practitioners:

5.1.1. Registered Health care professionals

I. It is the responsibility of the registered health care professional to

obtain consent from the patient prior to performing cannulation.

II. It is the responsibility of the registered health care professional to be consistent with standard precautions to be used during cannulation for all patients.

III. It is the responsibility of the registered health care professional to

monitor for signs of vascular access device infection.

IV. It is the responsibility of the registered health care professional, if any infection is detected, to manage this appropriately, including consulting with the infection control team and/or sending the cannula tip to the laboratory for culture.

V. Where a peripheral cannula has been inserted in an emergency

without an aseptic technique, it is the responsibility of the registered health care professional to replace this cannula within 24 hours.

5.1.2 Ward Manager/Team Leader

I. It is the responsibility of the ward manager/ team leader to ensure that

staff are aware of this policy and that working practice is in line with the policy described.

II. It is the responsibility of the nurse manager/ team leader to ensure that

nursing staff have the knowledge and the practical skills to deliver this care.

III. It is the responsibility of the nurse manager/ team leader to ensure that

the necessary equipment is available to carry out this procedure.

Page 11 of 35


Page 11 of

IV. It is the responsibility of the team leaders and ward managers to ensure that patients, in receipt of peripheral cannulation from healthcare professionals employed by Mersey Care NHS Foundation Trust, work to the standard requirements for intravenous cannulation (CINS Guidelines, Epic 2 Guidelines, NICE Guidelines)

5.1.3. In-Patient Service Manager/Intravenous Service Lead

I. It is the responsibility of the service manager to ensure that regular audit is carried out to measure the compliance to the requirements to this guideline. This may be delegated to appropriate employees, e.g. Matron.

II. It is the responsibility of the Intravenous Therapy Team Lead to review

this document

5.1.4. All Healthcare staff

All potential adverse incidents should be reported in line Mersey Care NHS Trust Accident and Reporting and Management Policy.

5.2 Method of placing a peripheral cannula

5.2.1 Patient selection:

• Short term administration of intravenous drugs (see table 1) • Rehydration (see table 2). • Transfusion of a blood component (see blood transfusion policy).

Table 1

• Intravenous antibiotic therapy should always be reviewed, stepped down and switched to oral as soon as possible. (BNF 2018)

• https://www.drugguides.co.uk/pub/bnf-76-british-national-formulary-september-2018-9780857113382.aspx?gclid=EAIaIQobChMIvtqdhIKY3wIVFp7VCh1NvgFBEAQYASABEgJYP D BwE

Page 12 of 35


Page 12 of

• If longer venous access is required, patients should be referred to the community intravenous team for the most suitable venous access device.

Page 13 of 35


Page 13 of

Table 2

• NB Intravenous rehydration is not a substitute for nutrition. For patients who have been undernourished for more than 5 days, nutrition therapy must be considered. (BAPEN)

• Discuss nutrition with the pharmacy and nutrition team.

Page 10 of 35


Page 10 of 31

5.2.2 Vein Selection (See appendix 1)

• Use dorsal hand veins first

• Use veins that feel soft and resilient

• Use large veins where possible

• Use straight veins suited to cannula length

• Use patient’s non – dominant limb, where possible

5.2.3 Cannula Selection

There are different types of cannula used for peripheral cannulation. Choice is determined by varying circumstances (see table 3)

Table 3

Gauge (G)

Flow rate ml/min

Colour

General uses

20

55

Pink Blood transfusions, large volumes of fluids

22

25

Blue

Blood transfusions, most medications and fluids

24

24

Yellow

Medications, short term infusions, fragile veins, children

Page 11 of 35


Page 11 of 31

5.2.4 Equipment Selection.

1.

Clean tray/trolley

2.

Sterile examination gloves

3

Clean tourniquet (disposable)

4

Cannula of the correct size

5

Dressing pack

6

Syringe (10ml) and Sodium Chloride 0.9% for flushing. * (Posiflush)

7

Spare gauze and tape

8

Sharps bin

9

Documentation :VIIAD charts (See appendices)

10

Prescription chart

Page 12 of 35


Page 12 of 31

5.2.5. INSERTION PROCEDURE INSERTION PROCEDURE

RATIONALE

1. Identify the patient as per Mersey Care NHS Foundation Trust policy.

To ensure correct patient.

2. Explain the procedure to the patient; ask for preference regarding site and obtain verbal consent and co- operation.

To ensure patient understanding Link to consent policy.

3. Discuss previous experiences and check need for local anaesthetic.

To establish venous history.

4. Prior to selection of equipment: • Hand wash with soap and water.

• Select the correct cannula size choosing the smallest gauge that will accommodate the patient’s infusion needs.

To minimise risk of cross infection To reduce unnecessary trauma to the vein.

5. Decontaminate hands using alcohol hand rub or by hand washing with liquid soap as per Mersey Care NHS Foundation Trust Hand Hygiene Policy

To minimize risk of cross infection.

6. Check integrity of packaging and expiry date before opening pack onto clean trolley/surface.

To maintain asepsis.

7. Wash and dry patients arm if visibly dirty.

Clean skin required.

8. Position the patient with arm supported by pillow or if required ensure assistance from a colleague. Place the drape under the patients arm.

To ensure patient comfort and safety.

9. Choose site according to patient condition and apply tourniquet at least 10cms above selected site.

To dilate veins by obstructing venous return.

10. Find the PALPABLE vein. To reduce trauma to the vein.

11. Decontaminate hands using alcohol hand rub;

To minimise risk of cross infection.

Page 13 of 35


Page 13 of 31

INSERTION PROCEDURE

RATIONALE

12. Disinfect site with chlorhexidine 2% in 70% alcohol for 30-60 seconds. Allow to dry. Use an alcoholic povidine-iodine solution for patients with a history of chlorhexidine sensitivity. Allow the antiseptic to dry before inserting the catheter. Allow to air dry. Do not re- palpate the vein or touch the skin.


13. Put gloves on and check equipment for

faults.

DO NOT WITHDRAW THE NEEDLE FROM THE CANNULA

To detect faulty equipment.

14. Anchor the vein by applying tension to skin below the site and insert the needle/cannula level up at 30-40 degree angle. Penetrate skin and advance into vein. Maintaining anchor tension with one hand and holding flashback chamber or thumb plate with the other, advance the cannula forward over the needle. Successful cannulation is confirmed by free flow of blood into flashback chamber. Slightly lower angle of cannula until almost flush with skin.

To immobilise the vein wall and to ensure a successful cannulation and this angle reduces risk of needle passing through the vein.

15. Adjust direction of cannula and advance a few mms into the vein and with draw the needle slightly, observing flashback of blood in shaft. Maintaining anchor tension with one hand and holding the flashback chamber or thumb plate with the other, advance the cannula forward over the needle.

To avoid the vein wall and to ensure cannula is in a patient vein.

To ensure the vein remains immobilised thereby reducing risk of venous wall puncture.

16. Only one vascular access device should be used for each cannulation attempt.

To maintain asepsis

17. Release tourniquet To decrease pressure in the vein

Page 14 of 35


Page 14 of 31

INSERTION PROCEDURE

RATIONALE

18. Apply digital pressure above tip of cannula and remove needle.

Discard directly into sharps bin. NEVER REINSERT THE NEEDLE

To reduce risk of needle stick injury

19. Attach the needle-free connector. To prevent air entry/protect against contamination.

20. Apply dedicated sterile highly permeable IV dressing (from pack)

To minimise risk of infection and to secure the cannula.

21. Flush the cannula with 2.5-5mls of sterile sodium chloride 0.9% for injection then commence IV therapy as appropriate.

To prevent occlusion.

22. Discard gloves and decontaminate hands.


23. Remove waste into appropriate container.

To ensure safe disposal.

24. A cannula inserted in an emergency situation where aseptic technique is compromised should be replaced in 24 hours.

To minimise risk of infection.

25. Document: Insertion time, Date, Site, Size of cannula, Batch number Name of person inserting the device. Record the review/removal date (72 hours).

See 5.1.1.V above

To meet legal and patient care requirements.

Page 15 of 35


15

5.3 MANAGING THE PERIPHERAL CANNULA WHILE IN SITU

MANAGEMENT OF THE CANNULA

RATIONALE

1. The number of lines and ports will be kept to a minimum consistent with clinical need

To reduce the risk of cross infection (DH 2018))

2. A needle free system should always be used on all vascular access devices.

RCN (2017)

3. IV administration sets should always be changed:

• At 24 hour intervals

• When the vascular device is replaced

Blood transfusion administration sets should be changed: • as new for each new solution

• Administration sets should be changed with every unit of blood (or every 4 hours, whichever is the shortest)

DH (2018) https://journals.lww.com/.../Are_you_up_to_date_with_the_infusion_nursing.12.aspx

4. Discard intermittent administration sets after each use e.g. antibiotic infusion bags. Never disconnect an IV line for

reattaching later

To reduce the risk of infection

5. The maximum expiry date for any infusion prepared in a clinical area is 24 hours or less in accordance with the manufacturer’s specification of product characteristics.

DH (2018) – to help avoid the risk of infection

6. Bandages should be avoided wherever possible. However, if a bandage is used it should be removed at least daily or once every 8 hours in a patient setting in order to inspect the insertion site. Clean Tubifast is an alternative

Early detection of any infection.

https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=2ahUKEwio38-C6JDfAhWqNOwKHaOBA74QFjACegQIAxAI&url=https%3A%2F%2Fjournals.lww.com%2Fnursing%2Ffulltext%2F2007%2F07000%2FAre_you_up_to_date_with_the_infusion_nursing.12.aspx&usg=AOvVaw30xudQ48OIm1BWZQaVGizJ




Page 16 of 35


16


RATIONALE

7. Devices designed for splinting should be used to facilitate infusion delivery only when the device is placed in or around an area of flexion or is at risk of dislodgement e.g. being used in a child:

• Splints should be removed and the circulatory status of the patients` extremity should be assessed at regular intervals.

• Splints must be effectively decontaminated between patients

RCN (2017)

8. When manipulating the line/cannula an aseptic non-touch technique should be applied. Ensure equipment in contact with the circuit is sterile e.g. syringes

To prevent cross infection RCN (2017)

9. Prior to access, use chlorhexidine 2% in 70% alcohol (single use wipe) to disinfect needle free device, unless contraindicated by manufacturers recommendations in which case use 70% alcohol

Essential to prevent entry of micro-organisms into the system via the portal

10. The cannula should be flushed at least once daily and pre and post drug administration with 2.5ml – 5ml sodium chloride for injection (0.9%) in a 10ml syringe. *The sodium chloride (0.9%) should be prescribed on the drug chart/prescription sheet if using ampoules and not Posiflush device

To maintain patency

11. The dressing should only be To reduce the risk of cross changed when it becomes loose, infection damp or soaked if dressing is clean and intact then do not disturb. Document this in the patient’s record

Page 17 of 35


17


RATIONALE

12. An aseptic non-touch technique should be used when changing the dressing as per Merseycare NHS Infection Control and Prevention Manual

Skin cleansing/antisepsis of the insertion site is one of the most important measures for preventing cannula related infections. See section 5.7

13. A cannula that has migrated externally should not be re advanced prior to re stabilisation

To reduce the risk of cross infection

14. The site should be examined to ensure the device has not become dislodged, for signs of infection and extravasion.

To identify mechanical complications and signs of infection.

15. If VIP score = 2 then remove cannula. If an infection is suspected or VIP > 2 then do the following :

1. Take a swab and send to

laboratory for Culture & sensitivity

2. Take the tip of the cannula and sent to laboratory for culture & sensitivity (see section 5.7)

3. Complete an IR1 4. Report any infection to Infection

Control Team and IV therapy team Leader.

The microbiology results may indicate which antibiotic is required should the patient develop signs of septicaemia

16. Along with any incidence of phlebitis, intervention, treatment and corrective action should be documented in the patient’s notes

To provide evidence of any action taken and aid communication

Page 18 of 35


18


RATIONALE

17. Peripheral cannulae should not be used for routine blood sampling. However, if necessary, the cannula can be used to draw blood using a syringe no larger than 10mls) ONLY ONCE immediately following insertion.

Reapply the tourniquet above the cannula, wait for vein engorgement and draw blood SLOWLY using minimal force.

RCN (2017) To prevent haemolysis in the sample

To prevent thrombophlebitis of the vein

18. If a peripheral venous cannula is not being used/required for access, it must be removed.

The longer a peripheral venous cannula remains in situ, the greater the risk of infection.

5.4 REMOVAL OF PERIPHERAL CANNULA

5.4.1

Equipment selection :

1

Examination gloves

2

Alcohol Gel

3

Sterile gauze and tape

3

Sharps bin

Page 19 of 35


19

5.4.2

REMOVAL OF PERIPHERAL CANNULA

RATIONALE

1. Peripheral cannula should be re-sited every 72 hours wherever clinically possible

DH (2017)

2. Removal of the intravenous cannula should be an aseptic procedure

To prevent cross infection/contamination of the catheter tip

3. Explain procedure to the patient and gain consent

To ensure patient understanding

4. Decontaminate hands using liquid soap as per as per Mersey Care NHS Foundation Trust Hand Hygiene Policy

To reduce cross infection

5. Apply clean examination gloves as per Mersey Care NHS Trust Standard Precautions Policy

To maintain universal precautions

6. Remove dressing To expose cannula site

7. Hold sterile gauze over site and gently withdraw cannula using a slow, steady movement, keeping hub parallel with skin

To ease withdrawal and prevent damage to the vein

8. Check integrity of cannula before disposing into sharps bin

To ensure all removed

9. Apply pressure for 2-3 minutes with sterile gauze

To prevent bleeding and possible haematoma

10.When bleeding has stopped apply gauze dressing

To aid healing

11. Document the date and time and removal in the patients notes including the name and designation of the person removing the device

To meet legal requirement

12. If the site appears infected (VIP score of 2 or greater), a swab should be taken and sent with the tip of the cannula to Microbiology for culture and sensitivity See section 5.7

The microbiology results may indicate which antibiotic is required should the patient develop signs of septicaemia

Page 20 of 35


20

5.5 Documentation Process Documents titled: Visual Inspection of Intravenous Access Device (VIIAD). (See appendices) will reflect the process of care of a cannula, the cannula condition and specific nursing actions taken to resolve or prevent adverse incidents (see table 4):

The Viiad document is to be completed on each shift.

If the cannula has been sited in Secondary care the Viad documentation should be transferred with the patient. See appendix 2.

VIAD documents are to be kept in the patient’s case notes.

Table 4

Erythema score, used to detect complications in intravenous therapy is a reliable indicator on white skin. In some cases of black skin, it may be masked.

For guidance on detecting skin changes. See VIADS.

Also note that there are many other signs and symptoms to detect abnormality.

5.7 Managing a cannula related infection. (see 5.1.1.V, above)

5.7.1 Phlebitis:

Phlebitis can predispose to infection. • Ensure adequate skin preparation • Ensure sound hand washing and aseptic techniques at every contact • Closely monitor with VIIAD tool. • If cannula is not being used it should be removed as a potential cause

of infection. 5.7.2 Infected site

If the insertion site appears infected (VIP score > 2 or more), the tip of the cannula should be sent for culture & sensitivity.

Page 21 of 35


21

It is easy to contaminate the cannula tip on removal by wiping across the surface of the skin. Therefore when taking a cannula tip for culture, follow these instructions:

(I) Swab the surrounding skin and any pus. (2) Clean the surrounding skin with chlorhexidine 2% in 70% alcohol and

allow it to dry fully. (3) Remove the cannula and with sterile scissors, snip 1cm of the cannula

into a sterile container. (4) Use separate containers for each and send both the skin swab and the

cannula tip to the laboratory. (5) Inform Infection Control Team and IV Therapy team Leader if infection is suspected.

6. Training Requirements

Training to recognised practitioners must be fulfilled using a recognised competency framework, which relates to a completed a programme of preparation founded on principles of theory and practical learning, linked to a practical assessment provided by IV Therapy team. Please refer to training needs analysis. Practitioners will be expected to sign a declaration of cannulation practice. See Appendix 5

Competency will be guided by Merseyside and Cheshire Cancer Network with the Royal Liverpool and Broadgreen Hospitals NHS Trust, Clatterbridge Centre for Oncology, Mersey Care Community IV team and all trusts and PCTs within the North West Merseyside and Cheshire Strategic Health Authority, where consensus has been universally agreed relating to guidelines, competencies, care plan and resources. See Appendix 6 for competency sign off sheet.

This process of this is ensured by the Intravenous Services Lead and In- Patient Kent Lodge/CCAU, Matron who will be responsible for ensuring that their own practitioners’ learning, assessment and peer review. That is within the in-patient unit, the Community Clinical Assessment Unit is the designated area for this training and Intravenous peripheral cannulation practical training is provided by the unit’s Nurse Clinician and the IV Therapy team. Within the community intravenous team services, the practitioner will receive learning, assessment and peer review, including cannulation practical training within the community by the intravenous team leader.

On completion of training, Mersey Care NHS Foundation Trust will have on record (Learning and Development Bureau) that the practitioner and the Trust are confident that the practitioner has the skills and knowledge to practice safely and effectively as defined by the NMC, scope of professional practice (NMC 2017).

Page 22 of 35


22

7. Implementation, Monitoring and Review 7.1 The Chief Executive is responsible for implementing this policy. This process has been delegated to the Intravenous Service Lead and In-patient Services Matron.

7.2 The Director of Operations and Executive Nurse is responsible for ensuring that this document is reviewed and if required, revised in the light of legislative guidance or organisational change. This process will be delegated to the Intravenous Service Lead and In-Patient Services Matron.

7.3 Review shall be within one year unless practice changes in the interim.

7.4 Compliance with this document will be monitored by

• The Mersey Care NHS Foundation Trust incident reporting system to

the Trust’s clinical governance committee on incidences of infection.

• Clinical audit. This process is delegated to the Intravenous Team Leader for the community intravenous therapy team

• Audits will be devised in conjunction with Infection Control Team to monitor compliance with Nice Guidelines

• This process can be delegated to ward managers, Intravenous

Therapy caseload holders

• A Daily Visual Inspection Phlebitis score (VIP) (the uniform standard inspection scale (Jackson 1998) which are reflected within the VIIAD documents (see appendix 2) and retained in the patients’ case notes.

The Clinical Effectiveness lead or the Clinical Governance Team can be contacted for support/advice.

8. Impact Assessment

An impact assessment has been undertaken and evidence has been retained by both authors and the Equality and Diversity Lead, Mersey Care NHS Foundation Trust.

9. Linked areas/Associated Documents

Accident and Incident Reporting and Management Policy

Infection Control Policies

Page 23 of 35


23

CINS - Collaborative Intravenous Nursing Service. Cheshire Merseyside 10. Relevant Legislation/Statutory Requirements

Nursing and Midwifery Council (2008b) Code of professional conduct: standards for conduct, performance and ethics.

Royal College of Nursing (2010) Standards for Infusion Therapy, RCN, London

11. List of Appendices

• Appendix 1 – Vein Selection • Appendix 2 - VIIAD • Appendix 3 – Visual inspection Phlebitis Score • Appendix 4 – Declaration of cannulation practice • Appendix 5 – Competency assessment form

12. References

Anderson K N, & Anderson L E, (1995) Mosby's Pocket Dictionary of Nursing,

Medicine and Professions Allied to Medicine. Mosby London British Association of Parenteral and Enteral Nutrition (BAPEN)

British National Formulary (BNF 2018) Intravenous Antibiotic Therapy 5. Sept

page 282 British National Formulary (BNF 2018) Intravenous Nutrition Sept 9.3 p 518

CINS Collaborative Intravenous Nursing Service. Cheshire Merseyside

INS (2017) Standards for Infusion Therapy. Royal College of Nursing. IV

Therapy Forum appendix 6 Jackson A, (1998). A battle in vein: infusion phlebitis, Nursing Times (94) 4: 68-

71.

Perdue M B (2001) ‘Intravenous complications’. Infusion therapy in clinical

practice. 2nd edition. Pennysylvania: W B Saunders, Chapter 24, 418 – 445

Page 24 of 35


24

General Practice second edition. Oxford University Press p259 & p632

Royal College of Nursing Standards for Intravenous Therapy (2017)

Simon C, Everitt H, Kendrick T (2005), Basic Diagnostic skills. Oxford Handbook of General Practice

Page 25 of 35


25

Appendix 1 VEIN SELECTION

1. Cephalic vein 2. Basilic vein

Page 26 of 35

Patient Name: ……………………

Cha

nge

IV g

ivin

g se

t afte

r 72

hour

s. S

igna

ture

……

……

……

……

Appendix 2

VIIAD 1 Peripheral Cannula

Note: Use appropriate form for central lines.

Peripheral IV Cannula Visual Inspection of Intravenous Access Devices (VIIAD)

Ensure that this form is completed each shift by registered nurse. Document any variance overleaf. Use separate form for every peripheral IV cannula.

……………………………… Indication for Insertion………………………………………………………..

Unit No. ………………………………….. Insertion date …………………… Time …………………………… Ward ……………………………………… Cannula size/colour/type …………………. …………………………… Site ……………………… Inserted by…………………………… Designation ……………………… Skin disinfected with …………………………. Date

V.I.P. Score 0 – 5 (see overleaf)

Flushed? Yes/No/NA

Flow problems? Yes/No/NA

Dressing intact? Yes/No/NA

Shift Time

E L N E L N E L N Rationale for keeping cannula over 72 hrs.

………………………………… …………………………………

…………. Signature……………….

Is venous access required

for longer? Yes No

Moisture/leak from site? Yes/No/NA

Needle-free device/Octopus used? e.g bionector Yes/No/NA

Registered Nurse Signature

Printed Name

TO BE COMPLETED ON TIME ON TIME OF REMOVAL.

Date line removed ……/…../…… Time ……………….………………….. Reason for removal (circle) Elective VIP > 1 Dislodgement Other ……………………… Removed using aseptic technique by……………………………… Signature ………………………

If yes, refer to IV Therapy Team on 285 4696.

Referred by ………………………..

Referred on

.…/…/….

Page 27 of 35

IV site appears healthy

One of the following is evident: Slight pain near IV site Slight erythema near IV site Two of the following are evident: Pain at IV site Swelling Erythema All of the following are evident: Pain along the cannula Erythema Swelling All of the following are evident and extensive: Pain along the path of the cannula Erythema Swelling Palpable venous cord All of the following are evident and extensive: Pain along the path of the cannula Erythema Swelling Palpable venous cord Pyrexia

No sign of phlebitis Observe cannula Possible first signs of phlebitis Observe cannula Early stages of phlebitis Resite cannula Medium stages of phlebitis Resite cannula Initiate treatment

Advanced stage of phlebitis or start of thrombophlebitis

Resite cannula Initiate treatment

Advanced stage of thrombophlebitis

Resite cannula Initiate treatment

Appendix 3

Visual Infusion Phlebitis (VIP) Score

0

1

2

3

4

5

Page 28 of 35

Appendix 4

Declaration for Cannulation Practice

Name Job title Band

I confirm that I am competent to practice cannulation

I have; • Completed/updated as necessary the theory training according to my competence/confidence • Undertaken minimum 5 successful, supervised cannulations • Demonstrated competent practice • Read the associated Trust guidance and policies

I understand that I am responsible for keeping my practice up to date and am advised to read policies and procedures as and when they are reviewed.

Date for annual update reassessment Name Signature Date Copy for PDR

28

Page 29 of 35

29

Appendix 5

Assessment Record

Peripheral IV Cannulation Instruction: Please tick (√) if performed, cross (X) if not performed, or write N/A if deemed not applicable

Surname Forename Ward/Dept Assessment Dates

Assessor(s)

Skills

Lab

Correct equipment collected

Clean tourniquet Sterile glove Syringe, needle and normal saline Cannula pack with appropriate size of cannula

Checks packaging and expiry dates Transporting Safely transfers equipment to patient

Preparing the patient

Identifies patient and explains procedure Obtains consent from patient Encourages questions Establishes comfort and privacy of patient

Hand washing Washes hands using the Ayliffe technique Performs procedure

Selects appropriate limb Applies tourniquet safely and checks pulse.

Supports patient’s arm Selects appropriate vein Loosens tourniquet Cleanses patient’s skin aseptically with chlorhexidine 2% and allows to dry

Washes hands/ disinfects hands with alcohol hand gel

Opens equipment maintaining sterile field Places blue towel under chosen limb Reapplies tourniquet Disinfects hands with hand gel Applies sterile gloves Introduces needle safely until flashback Removes/loosens tourniquet Introduces of cannula carefully and withdraws introducer at the right time

Stabilises cannula Flushes cannula with normal saline Appropriate sterile dressing applied

Patient comfort & safety

Comfort of patient re-established Explains care of cannula to patient

Safety Disposes of sharps appropriately Maintains aseptic technique throughout

Hand washing Washes hands Documentation

Applies “Review by date” sticker Completes cannula insertion record Completes VIIAD form

If first attempt fails, one further attempt is permitted, if the principles of asepsis are maintained.

Page 30 of 35

39

Appendix 6- Image of Posiflush®

Page 31 of 35

39

Page 32 of 35

39