Vascular Access Devices

Vascular Access Matters ...because one small act can save - or cost - a life. Fade into video here for narrative

Introduction audio What is vascular access? Peripheral. Central. Proper care: saves lines, saves lives . Standardization of Care: new technology, new challenges: how to stay current?

2009 Joint Commission Hospital National Patient Safety Goals – select list As of April 1, 2009 : Hospital’s leadership has assigned responsibility for oversight and coordination of the development , testing, and implementation of NPSG.07.04.01 As of October 1, 2009 : Pilot testing in at least one clinical unit is under way, for the requirements in NPSG.07.04.01 As of January 1, 2010 : The hospital educates health care workers who are involved in these procedures about health care associated infections, central line-associated bloodstream infections, and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in these procedures is added to an individual’s job responsibilities. Prior to insertion of a central venous catheter, the hospital educates patients, and their families as needed, about central line-associated bloodstream infection prevention. The hospital implements policies and practices aimed at reducing the risk of central line-associated bloodstream infections that meet regulatory requirements and are aligned with evidence-based standards (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines).

2009 Joint Commission Hospital National Patient Safety Goals (cont’d) As of January 1, 2010 , the following will be required: The hospital conducts periodic risk assessments for surgical site infections, measures central line-associated bloodstream infection rates, monitors compliance with best practices or evidence based guidelines, and evaluates the effectiveness of prevention efforts. Use a catheter checklist and a standardized protocol for central venous catheter insertion. Use a standardized supply cart or kit that is all inclusive for the insertion of central venous catheters. Use a standardized protocol for maximum sterile barrier precautions during central venous catheter insertion. Use a chlorhexidine-based antiseptic for skin preparation during central venous catheter insertion in patients over two months of age, unless contraindicated. Use a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports.

Evidence Based Practice audio 25% of all CVC usage results in occlusion 1 . ~ $100,000 of TPA used for PICC catheter clearance @ FAHC 10/07-03/08. (Does not include expenses of nursing time, supplies, delay of treatment, catheter replacement.) 1 Deitcher S, Fesen MR, Kiproff PM, et al. Safety and efficacy of alteplace for restoring function in occluded central venous catheters: results of the cardiovascular thrombolytic to open occluded lines trial. J Clin Oncol. 2003;20(1):317-324.

Evidence Based Practice (cont’d) audio Catheter related bloodstream infections (CRBSI) are the most costly & life threatening of all healthcare infections. Between 14-28,000 patients die annually due to central line infections. CRBSI cost up to $29,000/case, and prolong hospitalization by a mean of 7 days. Since October 1, 2008, CMS will not reimburse for hospital acquired CRBSI 5 Million Lives Campaign. Getting Started Kit: Prevent Central Line Infections How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2008.

Principles Of Asepsis Fade into video here for narrative

Principles of Asepsis audio Medical Asepsis clean: reduce and prevent spread of microorganisms Surgical Asepsis sterile: aim to eliminate microorganisms Contamination – caused by: prolonged exposure to air wicking (capillary action) from wet areas out of field of vision objects below waist touched by non-sterile objects bedsheets, skin, contaminated syringes/tubing

Asepsis: video See notes below

Biofilm audio Fibrin is not necessary to make biofilm All indwelling devices have biofilm Biofilm formation begins immediately “… Biofilm forms when bacteria adhere to surfaces in aqueous environments and begin to excrete a slimy,glue-like substance that can anchor them to all kinds of material…” Center for Biofilm Engineering, Montana State University permission P. Stoodly

Used with permission audio Almost all micro-organisms are embedded in matrices of these complex biofilm communities, or colonies. Biofilm begins forming on vascular access devices almost immediately upon contact with the patient’s bloodstream. The biofilm allows the micro-organisms to adhere to any surface, living or nonliving. Microbial biofilms are responsible for 65% of infections treated in the developed world. The adaptive and genetic changes of the micro-organisms within the biofilm make them resistant to all known antimicrobial agents 1 . Vascular catheter-related bloodstream infections are the most serious and costly healthcare-associated infections – and the most life threatening. 87% of primary bloodstream infections are associated with an intravascular device 2 . 1 Ryder, Marcia; “Catheter-Related Infections – Its All About Biofilm”; Topics in Advanced Practice Nursing e-Journal. 2005;5(3) ©Medscape 2 Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System. Crit Care Med. 1999;27:887-892 .

Problem: – Infection audio With permission Biofilm clusters with streamers Showing flow in channel (e.g. blood vessel) Biofilm: slimy glue like matrix created by bacteria that cannot be eliminated and is resistant to antibiotics. 1 Planktonic intra or extraluminal ‘clumps’ can be released into the bloodstream. 1 Catheter-Related Infections: It's All About Biofilm, Marcia A. Ryder, PhD, MS, RN Topics in Advanced Practice Nursing eJournal. 2005;5(3) ©2005 Medscape, Posted 08/18/2005

Know your VAD! (vascular access device) Fade into video

know your VAD! pretest A non-valved catheter has clamps. T F Vancomycin should be given through a midline. T F A triple lumen subclavian line is considered a valved catheter. T F

know your VAD! PICC = ‘Peripherally Inserted Central Catheter’ Midline = long peripheral catheter Tunneled catheter = long term central catheter that has a portion implanted through a tract created in the tissue Chest groshong, Hickman, Broviac Non-tunneled = short term central catheter Cordis IJ, subclavian line, femoral line Dialysis catheters NOTE WELL: Dialysis catheters may ONLY be used for infusion with order from Renal Attending/Fellow, and ONLY be accessed by Dialysis RN or IV RN with competency training and assessment.

Know your VAD! vascular access device audio Where is the catheter tip? Where is the catheter inserted? Valved or non-valved? Power injectable? Type of needleless connector?

Central: required for administration of many agents/medications PICC tip placement Non-fluoro PICCs confirmed by CXR MUST be verified by an IV RN even attendings may not release these PICCs for use Catheter migration? Consult IV RN Malpositioned catheters may pose serious risk Staff RN’s: document length of external catheter. Optimal central catheter tip placement is essential… audio

Know your VAD! vascular access device audio Central: terminates at or near the heart. Peripheral: short (~1 inch); usually in forearm. Midline: ~6-8 inches, terminates in upper arm. Where’s the catheter tip? Film courtesy J. Bowen-Santolucito Optimal tip location:

Know your VAD! vascular access device audio Where is the catheter inserted? Arm Groin Chest Subclavian Neck/Internal or External Jugular Flank Umbilicus Leg/foot

Know your VAD! vascular access device Valved or non-valved? audio Hickman, broviac Power PICC Groshong (PICC or chest) Nontunneled ( subclavian, IJ) Solo Power PICC N O N V A L V E D V A L V E D C L A M P when not in use Don’t have clamps Don’t require heparin valve  valve at tip

Know your VAD! Infusaport (port, portacath, IVAD; many types) audio Huber needle Device under tissue IV tubing Power Port Power injectable Consider all ports NONvalved unless you know it is Groshong When a port is not in use, or not accessed , monthly flushing is usually required to maintain patency. When a port is in use, the non-coring needle should be changed, and the device flushed, weekly .

Know your VAD! vascular access device audio Samples of Power injectable Power PICC (Bard) Solo Power PICC (Bard) Arrow Pressure Injectable Valve  valve  clamps

Know your VAD! Needleless connectors pretest Evidence based : A ____ second scrub of hub will provide adequate disinfection. Catheter related infections related to inadequate disinfection can most likely be classified as a. intraluminal b. extraluminal

Know your VAD! Needleless connectors audio Remember: A majority of blood stream infections related to central lines are caused by improper care and accessing . Can you name these needleless connectors? “ All models of needleless access ports were successfully disinfected..” with 15 second scrub with isopropyl alcohol (IPA). Wendy, MT, MPH, CIC and Chinn, Raymond, MD, FACP “Successful Disinfection of Needleless Access Ports: A Matter of Time and Friction”, JAVA (12; 3) 2006 pps 140-142 Alaris Smart Site ICU Medical Microclave ICU Medical CLC 2000 ICU Medical Clave

Which line for what? Some vascular access devices can be used for any infusion therapy Some infusion therapies are contraindicated via certain vascular access devices Usually because of risk to patient’s tissue Clinicians must know the difference, and are legally liable

Which line for what? audio CT: plain – any line power injection: only power catheters Chemo central (rare peripherally) Antibiotics most (some abx should only be given centrally) Blood: any line (central lines with MD order) Fluid infusion or resuscitation, PCA: any line TPN: central lines

Which line for what? EXAMPLES audio Parameters pH <5 or >9 Osm. >5-600 mOsm Irritants, vesicants Parameters pH between 5-9 Osm. <5-600 mOsm No irritants or vesicants TPN CT (CAT scan) check for pressure injectability Any periph. infusate Chemo Some abx (‘cillins, Vanco, Ceftaz., Ceftriax…) Inotropic meds (dopamine, dobutamine…) Central PPN for limited time CT (CAT scan) IV fluids – (most) Blood products Some abx Peripheral, midline

Which line and how to flush? Patients now have central line maintenance order forms. audio Please refer to actual order forms located on your unit. 10 unit/ml 2.5-3ml after sodium chloride flush 100 unit/ml 5ml in chest port after sodium chloride flush NA N/A Heparin Flush All Lumens 10 ml before and after each dose 20ml after blood draw 10 ml every twelve hours if not in use 10 ml before and after each dose 20 ml after blood draw 10 ml monthly if not accessed 10 ml every twelve hours if accessed 10 ml before and after each dose 20 ml after blood draw 10ml monthly if not accessed 10 ml daily if accessed 10 ml before and after each dose 20 ml after blood draw 10 ml every week if not in use Sodium Chloride 0.9% Flush All Lumens Power PICC, Hickman, Broviac, Mid-line, Per Q Cath Chest Port Groshong Chest Port Groshong, Vaxcel, Solo PICC, Mid-line Catheter Non-Valved Catheters Valved Catheters ADULT Line Maintenance -adults Less Than 10 kg 10 unit/ml 5 ml daily after Sodium Chloride flush 10 units/ml 2.5 to 3 ml daily after Sodium Chloride flush for Broviac and Hickman only. Power PICC every 12 hrs Greater Than 10 kg 100 unit/ml 5 ml daily after Sodium Chloride flush NA NA Heparin Flush All Lumens Note: < 5kg, use preservative free Heparin 5 ml before and after each dose 10 ml after blood draw 5 ml every twelve hours if not in use 5 ml once a month if not accessed 5 ml every 12 hours if accessed 5 ml before and after each dose 10 ml after blood draw 5 ml once a month if not accessed 5 ml daily if accessed 5 ml before and after each dose 10 ml after blood draw 5 ml Weekly if not in used 5 ml before and after each dose 10 ml after blood draw Sodium Chloride 0.9% Flush All Lumens Broviac, Hickman Power PICC Chest Port Groshong Chest Port Groshong, Vaxcel, Solo PICC, Midline C. Catheter Non-Valved Catheters Valved Catheters PEDI Line Maintenance Heparin weight based use adult sheet if over 30 /kg

Problem Solving Central Lines Occlusion Emboli Extravasation/Infiltration Phlebitis Infection

Problem : – Occlusion video Appropriate line flushing – do not force Know your VAD – heparin, or saline flush? (reinforce prior learning) Don’t plunge syringe to bottom Check needleless connector (change every 72 hours and after blood draws), change prn When was needleless connector change documented? Is line positional? Should have blood return each time catheter is used. Nurse is liable for use of malfunctioning catheter. Order TPA, call IV RN when TPA on unit Video clip of exploding catheters/catheter aneurysm (Joann and Steve demonstrating)

Problem : – Occlusion video Nurse encounters plugged PICC line Hmmm, no blood return – plugged too. Is line clamped? “ should have used heparin?” “No, Steve – this is a valved catheter. I wonder if this patient has a catheter embolus?” Check needleless connector (change every 72 hours and after blood draws), change prn When was needleless connector change documented? Is there blood or precipitate in line?

Problem: Emboli audio Different types of emboli Air Catheter Wire Thromboembolus What is wrong with this picture? No connectors = potential air embolus What is wrong with this picture? Torn catheter = potential catheter embolus  Catheter tip Stylet (wire) Thrombus from subclavian vein Courtesy Deb Richardson

Problem: Emboli – Identification audio Medical Emergency Deep respirations Coughing Cyanosis Chest pain Gasping Weak pulse Low or absent BP

Problem: Embolus -Treatment audio CATHETER embolus (catheter fragment in bloodstream): THIS IS CONSIDERED A MEDICAL EMERGENCY: Immediate medical intervention is warranted. Implement strict bed rest. Immediately apply tourniquet PROXIMAL to the site to retain the fragment in the arm. Obstruct venous, not arterial flow. Assess pulses distal to tourniquet every 15 minutes. Initiate oxygen therapy. Notify physician, contact Interventional Radiology to prepare for emergent procedure. Monitor vital signs. Ensure patient has adequate peripheral IV access. Only MD should remove tourniquet. AIR embolus Clamp or kink catheter. Position patient on LEFT side in Trendelenburg. Call MD immediately. Administer oxygen, monitor vital signs, and setup for code 99.

Problem: Extravasation/Infiltration audio and Phlebitis Refer to NGP 117 Extravasation Photos courtesy Lorelle Wuerz, RN Dilantin extravasation Gross infiltration NOTE WELL: the following are considered actual or potential extravasants: Many chemotherapeutic agents Ampicillin, Nafcillin, Meropenem, Piperacillin-Tazobactam Vancomycin Phenergan (preferred route is IM, NOT IV) Transfused blood IV contrast Dopamine and Dobutamine

Problem: Extravasation: Action steps audio Intervention: Discontinue infusion immediately and disconnect the line. Leave the catheter in place until treatment is determined. Clamp if applicable. Initiate pharmacy consult and notify physician. DO NOT FLUSH Continue to follow policy (extravasation)

Problem: Extravasation/Infiltration Grade: 0 Clinical Criteria: No symptoms Grade: 1 Clinical Criteria: • Skin blanched • Edema <1 inch in any direction • Cool to touch • With or without pain Grade: 2 Clinical Criteria: • Skin blanched • Edema 1-6 inches in any direction • Cool to touch • With or without pain Grade: 3 Clinical Criteria • Skin blanched, translucent • Gross edema >6 inches in any direction • Cool to touch • Mild-moderate pain • Possible numbness Grade: 4 Clinical Criteria • Skin blanched, translucent • Skin tight, leaking • Skin discolored, bruised, swollen • Gross edema >6 inches in any direction • Deep pitting tissue edema • Circulatory impairment • Moderate-severe pain • Infiltration of any amount of blood product, irritant, vesicant Infusion Nursing Society Infiltration Scale NGP117

Problem: Phlebitis Action steps audio Peripheral lines: Stop infusion. Remove line immediately. Central lines: Stop infusion. Contact MD/IV Therapy. Document well. Criteria for Infusion Phebitis Grade 0 No symptoms Grade 1 Erythema at access site with or without pain Grade 2 Pain at access site with erythema and/or edema Grade 3 Pain at access site with erythema and/or edema Streak formation Palpable venous cord Grade 4 Pain at access site with erythema and/or edema Streak formation Palpable venous cord > 1 inch in length Purulent drainage Infusion Nursing Society Phlebitis Scale

Problem : Infection pretest If the nurse touches any pt. object after she performed hand hygiene, she must repeat hand hygiene immediately prior to handling vascular access devices. T F FAHC performs hand hygiene audits every __________________.

Infection: The Impact audio A Mother’s Letter to a Hospital CEO http://safecarecampaign.org/index.html hyperlink this.. Our son died in your hospital 7 days ago. He died from a bacterial infection he caught there as a result of his medical care while being treated for something else. It created so much pressure around his brain that it caused part of it to be pushed into his spinal column, leaving him a helpless ventilator-dependent quadriplegic and ending his short but unforgettable life among us all…….

……… ..Dear CEO, I hope you read this letter to your team aloud. Tell your board that we do not want anything for the loss of our dear son but a dramatic and effective plan for change that will make a difference for others who trust healthcare in general and your hospital specifically. We look to you to partner with us as patients and caregivers so that we may all be safe and well, both now, and in the future. Sincerely, Victoria Nahum audio

Problem: Infection audio Outcome of poor catheter and dressing maintenance. Note: sutures may have contributed to cellulitis. Standard of practice: catheter securement devices.

Infection: factors audio Use of contaminated administration sets, solutions, or medications Contamination of catheter needleless connector Catheter insertion technique Site of insertion Use of multiple lumen catheters Migration of organisms from insertion site Thrombosis, fibrin, biofilm, and catheter occlusions

Problem : – Infection – Disinfection of needleless connector video 1 show proper disinfection technique 2 show proper connector change technique

Integration (fade into video narration) how you practice. Transform into what you know

Catheter Site Assessment Fade into video

Catheter Site Assessment pretest When measuring external catheter length, you would measure the area marked by the white circle. T F

Catheter Site Assessment audio Assess all VAD sites for: erythema, induration edema (swelling) pain discharge catheter migration (measure external length of central lines) With permission J. Bowen-Santolucito Phlebitis from Nafcillin courtesy D. Richardson RN Cellulitis from subclavian line

Catheter Site Assessment audio junction Clue: if any catheter is visible outside of dressing – catheter has likely migrated. Measuring External Catheter Measure to suture wing junction Leave dressing in place Each hash mark represents one cm. How long is this PICC line’s external catheter length?  Insertion site

Intact, clean, dry dressing at all times Assure that catheters are properly secured to prevent dislodgement or damage Assess catheter for patency and blood return Avoid catheter rupture and embolus - don’t force! Contact an IV RN with questions or problems Catheter Site Assessment audio

Catheter Site Assessment video

Flushing and Infusion pre-test It is appropriate to have an IV line unclamped with blood in line; it’s the patient’s own blood. T F Why is it that a syringe smaller than 10ml should not be used to flush PICCs or other central lines?

Which line, and… how to flush? pretest Patient on Baird 4 has triple lumen subclavian line, with clamps on each lumen. How should this catheter be flushed after Vancomycin administration? With 20ml 0.9% normal saline, followed by heparin flush of 10u/ml With 20ml 0.9% normal saline, followed by heparin flush of 100u/ml With 10ml 0.9% normal saline, clamping line before end of heparin flush. With 20ml 0.9% normal saline, followed by heparin flush of 10u/ml, clamping line before end of heparin flush.

Flushing and Infusion video No visible blood in line 10ml syringe use No pushing through resistance 20ml after vanco,TPN, blood transfusion/sampling Stop flush before syringe is completely empty Keep end of tubing sterile/connected – no loop backs Keep exposed male luer end away from contact

Home Care Considerations video Short or long term use? Mandatory: pt./caregiver teaching Document well in discharge planning Process will involve nurse case manager Does patient have vendor services established?

Vascular Access Matters Resources audio FAHC IV Therapy 847-3647 Intradoc (hyperlink these) NGP0009 Central Venous Access Devices INFC00003 Prevention of IV Device Related Infections NGP 119 De-Clotting Central Venous Catheters Using Thrombolytic Agent tPA NGP00062 Peripheral Venous Catheters; Staff Responsibilities and Care of NGP00083 Peripherally Inserted Central Catheter (PICC); General Care NPG111 - Blood Drawing through Central Venous Access Devices

Coming in FY 2009: audio SVAT: specialized vascular access team, multidisciplinary oversight committee and work group “ Fistula First” program: preserving arm veins of renal patients for fistula placement. BEST PRACTICE.

Dressing Changes Create link here for people to bypass this section if they don’t need to see dressing change portion

Dressing Changes audio Central line dressing changes are performed by: the IV RNs. RNs from specialty units, who have completed standard FAHC competency training and assessment for this skill.

Dressing Changes pretest At FAHC, Central Line dressing change procedures are a. clean b. sterile c. either If a CVAD insertion site is covered by an ___________ dressing, it should be changed weekly and prn. Should patients wear masks during dressing changes?

Dressing Changes see Intradoc NGP0009 audio Perform hand hygiene EVERY time immediately prior to handling vascular access devices. MUST use sterile procedure and wear mask (for IVAD accessing as well). Home patients must wear mask; highly recommended for inpatients as well.

Dressing Changes audio Chlorhexidine and isopropyl alcohol (e.g. Chloraprep) is FAHC preferred antiseptic for central line insertion and maintenance. Instructions for use: scrub back and forth for 30 seconds, let air dry. One 3ml chloraprep covers 4”x5” area TIP: remove old dressing in direction of insertion site to avoid pulling catheter out. Catheter securement devices (e.g. statlock) are standard of practice over sutures – significantly reduce complications.

Post test (Go to post-test questions in Angel)

Vascular Access Devices

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