PORTSMOUTH HOSPITALS NHS TRUST Section 3.12
CLINICAL POLICIES
TITLE / CLINICAL POLICY FORPERIPHERAL VENOUS CANNULA INSERTION AND MANAGEMENT (ADULTS)
REFERENCE NUMBER / 3.12
MANAGER / COMMITTEE RESPONSIBLE / IV PROJECT LEAD
PARENTAL THERAPY GROUP
DATE ISSUED / 18.09.2007
VERSION / 4
REVIEW DATE / March 2008
Equality Impact Assessment has been applied to this policy / Simon Freathy, Clinical Nurse Specialist Intravenous Therapy
AUTHOR / B .BUCHANAN IV PROJECT LEAD/ SANDY KIRK CNS IV THERAPY
RATIFIED BY / CHAIR OF PROFESSIONAL ADVISIORY COMMITTEE: 17.09.2007
AMENDMENTS RECORD:
The text of this policy is unchanged from issue 3, only the focus on the distal extremities is different.
See appendix III
CONTENTS:
1. INTRODUCTION
2. STATUS
3. PURPOSE
4. SCOPE/AUDIENCE
5. DEFINITIONS
6. CLINICAL PRACTICE
7. SUPPORTING EVIDENCE
8. DUTIES AND RESPONSIBILITIES
9. TRAINING
APPENDICES:
APPENDIX I: CANNULA INSERTION AND MANAGEMENT FORM
APPENDIX II: SUPPORTING WARD INFORMATION
1. INTRODUCTION
This policy will provide information about the correct technique for peripherally cannulating a vein aseptically and the subsequent care of the peripheral venous cannulae. By using this policy the user will act to reduce the risks to patients and staff associated with peripheral venous cannulation. These include thrombosis, pain, local or systemic infection; occupational sharps injury and inappropriate cannula insertion.
Aseptic peripheral venous cannulation is undertaken to provide venous access for either diagnostic or therapeutic purposes:
a) Short-term intravenous fluid therapy of usually less than 3-4 days (if intravenous access is needed for longer periods, other options should be considered).
b) Administration of bolus injections in outpatients or in day case surgery
c) Vascular access for fluids or drugs at time of particular procedure e.g. surgery, endoscopy
The implementation of this policy will be monitored using clinical audit. !0 cannula audits monthly. (appendix I)
2. STATUS
Clinical Policy
3. PURPOSE
To inform best practice on the aseptic insertion of peripheral venous cannulation of adults. The implementation of this policy will reduce the risks associated with this procedure including thrombosis, pain, local or systemic infection; occupational sharps injury and inappropriate cannula insertion.
4. SCOPE/AUDIENCE
This policy applies to all health care professionals performing cannulation in the Trust.
For cannulation in paediatric areas, please refer to Infection Control.
5. DEFINITIONS
Aseptic Technique
Clinical practices used to protect the patient from micro-organisms by preventing contamination of wounds, manipulated devices and other susceptible sites. Aseptic technique involves the use of appropriate hand hygiene, use of sterile equipment, no touch technique and robust patient skin / site disinfection.
Venous Cannulation
Procedure for insertion of a hollow fine bore tube into the venous system
Health care professional
A registered or trained member of staff, including but not exclusively nurses, doctors and operating department practitioners.
Infection
Entry of a harmful microbe into the body and its multiplication in the tissues
Peripheral cannulaA specifically-designed flexible tube designed for insertion into a blood vessel,
with a proximal connector to allow injection or infusion of liquids. Sizes range from blue 22g, pink 20g, green 18g, grey 16g and orange 14g. 22-20g are optimal for administration of intermittent medications. 16- 14g are routinely used to administer fluids in acute situations i.e. haemorrhage
Phlebitis
Inflammation of a vein
Thrombosis
Formation, development or existence of a blood clot within the vascular system
6. CLINICAL PRACTICE
Action / Rationale
Identify clinical need for cannula insertion / To prevent inappropriate insertion and exposure to associated risks.
Identify patient by surname, first name and date of birth / To ensure correct identification of the patient
Explain the procedure to the patient, discuss the need for a cannula, obtaining verbal consent for procedure establishing whether patient has any known allergies / To ensure patient is informed of procedure and the risk of allergic reaction is minimised
Explain to the patient the importance of keeping the site clean and dry and advise of risks of infection / To ensure patient compliance and reduce risk of infection
Collect equipment needed including:
§ Dressing trolley
§ Sterile field with dressing pack or proprietary cannulation pack
§ Single use tourniquet
§ Sterile gloves
§ Sharps box
§ 2% Chlorhexidine and 70% alcohol (Deb) skin preparation
§ Local anaesthetic (1% lidocaine) orange needle and 2ml syringe/ insulin syringe
§ Cannulae - IV dressing
§ Saline flush / To ensure procedure is performed without disruption
Choice of cannula must be based on clinical need but the smallest cannula should be chosen to reduce risk of complications associated with larger bores.
Wash hands with soap and water as per the Trust Hand Hygiene Policy / To reduce the risk of infection
Place opened dressing / cannulation pack onto clean dressing trolley. Open sterile packs and lay out equipment within the sterile field.
Sanitise hands with alcohol gel or wash with soap and water / To reduce the risk of infection
Palpate potential sites these include:
§ The hand - a lower risk of phlebitis
§ The wrist or upper arm – increasing risk
§ The lower limb has a higher risk than the upper limb / To reduce risk of arterial rather than venous cannulation, and reduce risk of infection.
When potential site is identified position patient comfortably with appropriate limb below the level of the heart. Removing excess hair (shaving is not recommended – clippers are better) / To allow dependent veins to fill with blood
Local trauma can be caused by shaving, increasing risk of infection
Action / Rationale
Apply proximal single use tourniquet, without obstructing arterial flow Optimal time for application is 3 to 5 mins – if additional time is needed release tourniquet as vein will tend to “disappear”. / To distend veins
Encourage patient to exercise limb muscles (e.g. repeatedly making a fist and opening hand) / Muscle pump forces blood into veins to distend them further
Sanitise hands with alcohol gel or wash with soap and water and don sterile gloves / To reduce the risk of infection
Clean insertion site using a spiral motion from the proposed puncture site outwards with 2% chlorhexidine in 70% alcohol (from a bottle or pre-soaked wipe) for 30 seconds and then allow to dry / To reduce risk of infection
Administer local anaesthetic (1% lidocaine) which should be encouraged in all but the most urgent of cases.
Alternatively apply prescribed topical local anaesthetic cream 45mins prior to procedure / To ensure patient comfort
Inserting the cannula:
§ Gently pull on skin, distal and lateral to insertion site. Do not touch the cannula or the insertion site.§ Insert cannula (bevel uppermost) through the cleaned skin area at an angle of 20 degrees.
§ Advance until just in the vein and then lower the cannula until it is parallel with the skin (a flashback of blood is usually but not always seen at this point) / To “fix” the skin and the superficial veins underlying it.
To use the sharpened needle to introduce the plastic cannula into the vein.
Then, either;
a) Pull the needle back 1cm and push the cannula/needle into the vein up to the hilt
Or;
b) Hold the needle still and advance the cannula over the needle until the cannula is inserted up to the hilt / To introduce the cannula fully into the vein
In the event of unsuccessful cannulation of the vein withdraw the cannula from the puncture site and apply pressure with non woven swab / To minimise haematoma formation and /or excessive bruising
Prior to subsequent attempts at cannulation it is the responsibility of the individual practitioner to risk assess the difficulty of further attempts against their own registered competence and experience. If the practitioner anticipates the difficulty level to be beyond their scope of practice, then referral to more experienced, competent practitioners should be made / To ensure cannulation is always undertaken by competent practioners and minimise risks associated with failed attempts at gaining venous access
Remove the tourniquet and apply pressure on the proximal vein, close to the tip of the cannula – a second person may be required for this / To prevent excessive bleeding during needle-removal.
Remove needle and dispose of immediately into sharps container, cap off cannula with a sterile cap or attach intravenous fluids as appropriate / To reduce risk of needle stick injury and prevent blood spillage.
Secure cannula with a recognised, sterile cannula dressing, ensuring it is applied correctly (non-sterile, sticky-tape fixation or bandage is NOT acceptable). / To reduce risk of infection and secure cannula in position
Place ‘date for cannula review’ sticker to outside of dressing / To ensure timely review
Flush cannula with 1-2 ml saline if not being attached to infusion. / To ensure cannula patency
Document cannula insertion and removal by completing a Cannula insertion and management form for each separate cannula inserted. Once cannula has been removed this document is filed in the patients medical notes. / To establish an audit trail and monitor management of cannula.
DAY CASE patient’s cannula need only to be documented fully in the notes. A cannula insertion and management form is NOT required. / Cannula insitu for short period of time and then removed.
Ongoing cannula management:
Decontaminate hands before and after each patient contact. Use correct hand hygiene procedure as per trust policy. / To reduce the risk of infection
Always access cannula by cleaning with 2% chlorhexidine and 70% isopropyl alcohol, and allow to dry before administering fluid or injections. / To reduce the risk of infection
Swanlocks (bungs) should NOT be applied directly onto the cannula; single or double lumen extensions should be applied. / To prevent unwanted movement of cannula in the vein. Thus causing phlebitis.
Cannula site should be inspected at least twice a day and documented on the form. / Observe for signs of infection or phlebitis.
Cannula dressing should be, intact, dry and adherent. A date and time of insertion must be applied at point of insertion. / To ensure that the cannula is replaced or removed on time, thus reducing the risk of infection.
Remove cannula if there is no continuing clinical indication. / To reduce the risk of infection
Replace cannula in a new site after 72-96 hours, earlier if clinically indicated. / To reduce the risk of infection
Administration sets should be replaced immediately after blood and blood product administration, intermittent IV antibiotics and medicines. Heparin infusion lines should be replaced every 24 hours. All other fluid sets should be replaced after 72 hours. ALL giving sets should be labelled with date and time on commencement of use. / To reduce the risk of infection
7. SUPPORTING EVIDENCE
· Department of Health (2001) The epic Project: Developing National Evidence – based Policys for Preventing healthcare associated Infections Journal of Hospital Infection (2001) 47 (supplement)
· Donaldson I. (1999) Intravenous therapy in critically ill adults: developing a clinically and cost- effective approach Intensive and Critical Care Nursing No 15, 338-345
· Dougherty L, Mallett J (2001) The Royal Marsden Hospital Manual of Clinical Nursing Procedures
· Fifth edition. Blackwell Science
· Fletcher SJ; Bodenham A (1999) Catheter related sepsis: an overview – Part 1 British Journal of Intensive Care. March/April
· Infection Control Nurses Association (2001) Policys for preventing intravascular catheter related infection NICE (2003) (No. 4) Care of patients with central venous catheters Clinical policy 2 – Infection control, June 2003
· Polderman KH; Girbes AR (2002) Central venous catheter use. Part 2: infectious complications Intensive Care medicine 2002, Jan; 28(1): 18-28
· Portsmouth Hospitals NHS Trust Policys
§ Infection Control Policys - Intravenous Cannulation and Infusion therapy
§ Blood Transfusion Policy (Adult0
· RCN (March 2004) Good practice in infection control – Guidance for nursing staff
· RCN (Oct 2003) Standards for infusion therapy
· DoH ( July 2006) winning ways high impact working together to reduce healthcare associated infection in England-intervention 2b
8. DUTIES AND RESPONSIBILITIES
Supervisors of clinical practice will be responsible for monitoring compliance with the policys on an Ongoing basis.
The IV therapy Nurses will audit compliance as part of the infection control clinical practice audit process.
A snapshot audit to monitor clinical practice during cannula insertion and subsequent care will be undertaken annually.
9. TRAINING
Prior to undertaking any cannulation procedure, all staff must be able to demonstrate clinical competence and a clear understanding of the underlying principles of practice. This will be achieved by:
Nursing and other health care staff;
a) complete the Trust venous cannulation competency pack
b) attend a cannulation study day
c) complete a period of supervised clinical practice
(Staff who have been trained and practised in a previous post may be allowed to demonstrate an equivalent level of competence through a period of supervised practice only).
Medical staff;
Post registration house officer (PRHO) induction will include training by Trust trainers on local policys and principles of practice.
Senior House Officer’s and Registrars will be assumed competent unless identified otherwise by their supervisor. If problems are identified, the staff member will be required to:
a) complete the Trust venous cannulation competency pack
b) attend a cannulation study day
c) complete a period of supervised clinical practice
PHT Peripheral Venous Cannulation (Adults) Policy. Issue 4. 18.09.07 Page 2 of 16 Control Date: 22/09/08
PORTSMOUTH HOSPITALS NHS TRUST Section 3.12
CLINICAL POLICIES
APPENDIX I: CANNULA INSERTION AND MANAGEMENT FORM
FORM AVAILABLE FROM MEDICAL PHOTOGRAPHY (EXT3370). FORM NO: 08246
PHT Peripheral Venous Cannulation (Adults) Policy. Issue 4. 18.09.07 Page 2 of 16 Control Date: 22/09/08
PORTSMOUTH HOSPITALS NHS TRUST Section 3.12
CLINICAL POLICIES
APPENDIX II: SUPPORTING INFORMATION FOR CLINICAL AREAS
Abbreviated guide to peripheral venous cannulation (adult.)
Action
Identify clinical need for cannula insertion
Identify patient by surname, first name and date of birth
Explain the procedure to the patient, discuss the need for a cannula, obtaining verbal consent for procedure establishing whether patient has any known allergies