KEEPING CL STARTS STERILE The ICU RN role in placing central lines at the bedside

1. KEEPING CL STARTS STERILEThe ICU RN role in placing central lines at the bedside Lori Ritter RN, BSN, CNRN Vicki Beck RN, MN, CNS, CNOR, CNRN

2. Pre-planning • Assure informed consent…Have patient or family sign consent for procedure unless emergent • Discuss with proceduralist planned insertion site and planned medications • Sedation • Pain management • Possible paralytic • If time, physician/PA to write med orders. If not meds may be over-ridden in Omnicell for emergent administration. • Make sure orders are written by physician/PA prior to leaving the unit

3. Patient Readiness • If patient aware enough, explain what to expect • Head may be placed in trendelenberg and covered with drape • Nurse’s role • Provide comfort, communication, administration of meds • Position patient to top of bed • Place chux under and around area of insertion • Place towel roll between shoulder blades for SC site

4. Prepare for Emergency • 1000 mL normal saline in-line for fluid resuscitation if ordered • Ambu bag connected to O2 source • NRB mask if not ventilated • Yankaur connected to suction and turned on • Reversal agents for sedation and pain medications ~especially if not intubated

5. Prepare the Room Area • Arrange bed with clearance for proceduralist to access pt • Clear the over bed table completely – wipe clean with Sani-Cloth • Position spotlight to shine on insertion site • Place garbage can close for easy target

6. Prepare monitoring equipment • Patient attached to EKG, SaO2, BP cuff with frequency of BP taken Q 5 mins once procedure is underway • Bedside monitor readied with appropriate insertion screen pulled up (esp with PA catheter insertion) • Pressure modules and cables inserted • Prime pressure tubing using 500 mL NS. • Place in pressure bag • Transducer/s can be leveled and zeroed prior to insertion • Vigilance monitor set-up for ScVO2 TL catheter or CCO PA catheter • Ask if physician plans for in-vitro or in-vivo calibration • Most lean toward the in-vivo calibration because of sterile field contamination with the in-vitro calibration • Utilize critical elements if unsure of procedure

7. Ultrasound equipment • Sonosite ultrasound in room and ready to go • Sterile sleeve availability • Know how to navigate the screens the proceduralist will need to get to. You will be pushing the buttons as they are sterile • Power button • Depth • Transducer choice • View change

8. Central Line Cart • Cart should in room, opened, with expected needed supplies pulled prior to procedure • If isolation room, cart will remain outside of room • Designate a helper to pass through any additional items during procedure • Everyone in room during procedure will need to wear a mask and bouffant cap ~at minimum • Assisting RN should be prepared to step into sterile field • Have ready sterile gown and properly sized sterile gloves

9. Supplies to pull • Maximum barrier PPE for proceduralist • This is included in the CVC triple lumen kit • If not utilizing the CVC TL kit, pull the following for proceduralist • Bouffant cap • Mask with eye guard OR mask and goggles (if not wearing glasses) • Sterile gown • 2 pairs appropriately sized sterile gloves

10. Supplies, cont. • Catheter to be placed • CVC TL catheter kit • ScVO2 TL catheter kit • Introducer kit and correct PA catheter • Transvenous pacing wire and temporary pacemaker if needed • Full body sterile drape • 30 mL vial of NS along with syringe and needle for flushing catheter ports • Proceduralist may pull up, or RN may squirt into the well of kit….taking care to not contaminate sterile field • (i.e. do not reach across) • Stopcocks and caps for line

11. Replacing a CL • If procedure is to replace an old CL: • Need all new IV drips, tubings, and in-line filters • Prepare prior to procedure • NEVER connect old IV’s to new central line

12. Prepare the Patient • Assure informed consent • Provide patient comfort with position, meds, face shield • Assure “time out” and document

13. Hand Hygiene/Mask/Cap/Gown/Glove

14. Drape the Patient • Surgeon will lay drape on pt chest and open • Assist by touching only under side of drape to open • Drape is not to move once opened – so balance weight of drape or anchor • Respect sterile field – Avoid reaching over or touching

15. Maintaining the sterile field: • Place only sterile items within the sterile field. • Open, dispense, and transfer items without contaminating them. • Do not allow unsterile personnel to reach across the sterile field or to touch sterile items. • Do not allow sterile personnel to reach across unsterile areas or to touch unsterile items. • Recognize and maintain the service provider's sterile area. • If a sterile barrier has been wet, cut, or torn, consider it contaminated. • Do not place sterile items near open windows or doors. • When in doubt about whether something is sterile, consider it contaminated.

16. Defining the ICU RN’s role • PRIOR • Make sure all supplies needed are in room, and room set-up is conducive to the flow of the procedure. Know physician/PA’s expectations for specifics. • WASH HANDS and roll up your sleeves • Don bouffant cap and mask to wear throughout procedure • Use sterile procedure when working close to sterile field. Do not brush against, lean over, or touch, unless you are wearing sterile gloves. If you are the one placing the supplies on and preparing procedure sterile field, do not leave room after this has occurred to assure maintenance of sterility.

17. Defining the ICU RN’s role • DURING • Perform ‘Time Out’ at the start of procedure • Provide comfort to patient throughout procedure through communication, pain and sedation medication, and touch as able • Assist physician in the placement of the full body sterile drape by grabbing from underneath and pulling down completely over body • Monitor patient’s O2sats, HR, BP, sedation and pain levels and intervene as needed. Provide ongoing communication of patient status with physician/PA as procedure is underway • Assist as required with procedure (i.e. Anticipate need fortrendelenberg position,if requested make sure PAcatheter calibrated prior to insertion, don sterile gloves if assistance needed in sterile field, assist with Sonosite manipulation). ScVO2 catheter will be calibrated after placement (in-vivo)

18. Defining the ICU RN’s role • AFTER • Discuss disposal of the sharps with physician/PA to assure appropriately done • Monitor and recover patient from procedural sedation • Monitor for all s/s of possible complications (i.e. pneumo after central line placement, etc….) • Follow up with physician regarding post procedure CXR result and clearance to utilize placed lines • Complete the Central Line Insertion QI form. Return front page to Bill and second copy to GSRMC QI dept. • Document in NUR and assign individualized interventions • Include notation about the “Time Out”

19. Prevention of CLABSICentral Line Associated Blood Stream Infection • Hand hygiene • Maximal barrier precautions • Proceduralist to wear cap, mask, goggles, sterile gown and gloves • Sterile full body drape • Chlorhexidine skin antisepsis • At insertion • Daily CHG bath while patient in ICU • Optimal catheter site selection • Avoidance of the femoral vein • Daily review of the line necessity; with prompt removal of unnecessary lines

20. Maximum barrier • Maximum barrier PPE for the proceduralist is a standard of care and required for all CL placements • SHS is tracking all CL placements for 100% compliance • RN is empowered to stop procedure if full sterile PPE is not being utilized. If full PPE declined, must fill out unusual occurrence report

21. Defining the ICU RN’s role • Celebrate your commitment to keeping our patients safe!