Blood Collection & Blood Culture Collection Removal Preventing Infection Needle-Free Valves

1. Are central lines driving you crazy?  Insertion Central Line Bundle Care & Maintenance TPN Flushes Blood Collection & Blood Culture Collection Removal Preventing Infection Needle-Free Valves

2. What you need to know when a central line is necessary…

3. Central Venous (Vascular) Access Devices: Insertion, Care and Maintenance, Blood Collection & Removal of [D-04], NPPM St . Luke’s University Health Network Annual 2014 Education for Nurses – updated 4/2014

4. Why? • Significant policy & practice changes and reminders regarding central lines! • Prevent infections! • Best practice!

5. Policy & Practice Expectations... Central Venous (Vascular) Access Devices Preventing Infection Insertion Removal Central Line Bundle Care & Maintenance Blood Collection & Blood Culture Collection Flushes Needle Free Valves TPN

6. Policy & Practice Expectations • An Informed Consent shall be obtained for the insertion of central lines, including PICCs, with the exception of emergency situations. • Secure ”Central Line Insertion Form” (#16264NP) to serve as guide and provide documentation of the insertion procedure (new attachment to policy). Although this information should not be new to practice, the wording is new to the nursing policy. Insertion Preventing Infection Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

7. Policy & Practice Expectations • Any line inserted emergently that was not placed under strict adherence to Central Line Bundle will be labeled, ”Emergent Line – insertion date: ____, time: ____.” Person inserting the line is responsible for labeling line accordingly. Typically the line should be removed within 24 hours of insertion. • Central lines inserted into the femoral vein should be removed within 24 hours of insertion unless otherwise directed by the physician. 24 HOURS ONLY Insertion Preventing Infection Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

8. Policy & Practice Expectations • Any member of the health care team present during a central line insertion, including the nurse, must • the process if any aspect of the Central Line Bundle process is not complied with. f Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

9. Policy & Practice Expectations • Central line sites are assessed and site assessments are documented minimally upon first contact with the patient (e.g. at the beginning of shift, receipt of transfer, etc.) and with any changes or complications noted. • Assess site for redness, swelling, warmth, tenderness, leaking, drainage, blood return, dressing integrity, etc. • Promptly report any signs of infection or other complications, e.g. catheter occlusion, to the physician. Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

10. Policy & Practice Expectations • A physician’s order is needed to access a permanent venous access device, e.g. Port-a-Cath. • To access a permacath requires a nephrologist’s order. Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

11. Policy & Practice Expectations • Dressings are to be changed: • Every 7 days or when the integrity of the dressing is compromised, loose, or soiled. • If gauze dressing is used,every 2 days or when the integrity of the dressing is compromised, loose or soiled. • PICC – 24 hours post insertion, then every 7 days. Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

12. Policy & Practice Expectations Please note… Dressing ChangeProcedure: 1. Perform hand hygiene. 2. Open dressing kit, maintaining sterility. 3. Don mask (self, and patient if unable to turn head to side away from catheter). 4. Put on non-sterile gloves. Remove old dressing in the same direction as the catheter was inserted and discard with gloves. Perform hand hygiene. Assess site for tenderness, redness, edema or drainage. Apply sterile gloves. Cleanse catheter insertion site with chlorhexidine following manufacturer's instructions for use. Allow to dry completely. Apply sterile dressing from kit. Apply label to dressing with time, date and initials. 12. Change needle-free valve(s) if no continuous or intermittent IV is infusing into lumen(s). Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

13. Policy & Practice Expectations • Reminders: • Any central line (including PICCs) inserted for the purpose of TPN administration will have one lumen dedicated and labeled as follows: “TPN-do not inject/withdraw”. Labeling is to occur immediately post insertion and is the responsibility of the person inserting the central line. • If a nurse is starting TPN for the first time on an existing central line that has not been previously labeled, the nurse must attach the label to the lumen selected for TPN administration. Preventing Infection Insertion Removal Central Line Bundle Blood Collection Care & Maintenance Flushes TPN Needle Free Valves

14. Policy & Practice Expectations • Needle-free valves are to be changed: • With each tubing change. • With dressing changes when no continuous or intermittent IV is infusing into a lumen. • Whenever the integrity of needle-free valve is compromised. • When residual blood remains in the needle-free valve. Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Needle Free Valves Flushes TPN

15. Policy & Practice Expectations Question: What does this mean? Needle-free valves are to be changedwith dressing changes when no continuous or intermittent IV is infusing into a lumen. Answer: - If a lumen of a central line has a needle-free valve which is not being used for any IV infusion, the valve would not be changed because there would be no tubing changes... - Therefore, the needle-free valve must be changed with the dressing changes. Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Needle Free Valves Flushes TPN

16. Policy & Practice Expectations • Flush Protocol (attachment to policy) Updated: • Highlights practice expectations in policy. • Flush after blood draws standardized to 10 mL normal saline. Preventing Infection Insertion Removal Central Line Bundle Care & Maintenance Blood Collection & Blood Culture Collection Flushes Needle Free Valves TPN

17. Policy & Practice Expectations • Every effort should be made to utilize the same port each time a blood specimen is collected. • All IVs infusing into all ports of central venous catheters must be stopped one minute prior to specimen collection. • Vasoactive solutions should not be stopped. • Blood samples should not be drawn from the lumen dedicated for TPN. Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

18. Policy & Practice Expectations • In order to maintain a closed system, blood samples should be collected, without removing the needle-free valve, by using a vacutainer blood luer adapter and blood collection tubes OR syringe and blood transfer device. Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

19. Policy & Practice Expectations • Blood Culture Collection: • A central line should be used to obtain blood cultures only as a last resort, and use for this purposerequires a physician’s order. (Exception: It is acceptable to obtain a blood culture upon insertion of a new central line.) • Prior to using a central line for drawing blood cultures, two (2) collectors should attempt a venipuncture on a patient. • If a blood culture is drawn from a central line, this must be done under sterile conditions and the needle-free valve must be changed prior to draw. • Further details are available in nursing and lab policies on MyNET. Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

20. Policy & Practice Expectations • A physician’s order is needed prior to removing a central line. • Patient Care Units, based on patient population, will determine the types of catheters that validated RNs will be allowed to remove. The validation process must be specific to catheter type. The following temporary catheters may be removed by validated RNs: • Introducer (e.g. Cordis) • Multi-Lumen Small Bore Catheter (e.g. Triple Lumen) • Multi-Lumen Large Bore Catheter (e.g. AVA) • Temporary Dialysis Catheter (e.g. Medcomp, Quinton) • PA Catheter (e.g. Swan Ganz) • Venous Sheath • PICC • RNs may not remove the following catheters: • Tunneled Dialysis Catheters (e.g. Permacath) • Tunneled Catheters (e.g. Hickman, Groshong, Broviac, Tunneled Cuffed PICC) • Implanted Catheters (e.g. Port-a-Cath) Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

21. Policy & Practice Expectations Should it be determined by the physician that the patient is to be discharged with a central venous catheter in place, a post-hospital plan for catheter care must be developed prior to discharge. Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

22. Policy & Practice Expectations... Please view these attachments online when policy is released in January… The protocols and guidelines are great resources for practice. Central Venous (Vascular) Access Devices • Policy attachments now include: • Flush protocols – adult • Flush protocols – pediatrics • Central line insertion form • Procedure guidelines: • Blood withdrawal from central venous catheters • Obtaining blood cultures from central venous catheters • Central line removal • PICC line removal Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

23. Policy & Practice Expectations • Ask daily, ”Does the patient really need a central line??” • Remember to ALWAYS assess and reassess the patient for ability to insert peripheral access. Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

24. Policy & Practice Expectations • Remember the central line bundles! • Hand hygiene! • Aseptic technique! • Insertion bundle • Maintenancebundle • Daily line necessity with prompt removal of unnecessary lines Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

25. Policy & Practice Expectations • Patient Education Reminders: • Use Krames On-Demand • Always educate patients on central lines and preventing infection • When education is provided use Teach Back method to validate learning • Documenteducation provided Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes Needle Free Valves TPN

26. TARGET ZERO – CAUSE NO HARM Know it, own it, do it! No Central Line Infections HAND HYGIENE & ASEPTIC TECHNIQUE EXCELLENT PRACTICE CENTRAL LINE BUNDLES

27. Policy changes go live date… January, 2014 – Stay tuned for P & P Memo Release

28. Don’t forget to take the test… Thank you! CL- CRZY