Peripheral Intravenous Cannula, Adults and Children (Not ...



Canberra Hospital and Health ServicesProcedurePeripheral Intravenous Cannula, Adults and Children (Not neonates)Contents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc517766918 \h 1Purpose PAGEREF _Toc517766919 \h 2Alerts PAGEREF _Toc517766920 \h 2Scope PAGEREF _Toc517766921 \h 3Section 1 – Site selection and insertion of PIVC PAGEREF _Toc517766922 \h 3Section 2 – PIVC post insertion care and management PAGEREF _Toc517766923 \h 6Section 3 – PIVC Administration Sets (changing and frequency) PAGEREF _Toc517766924 \h 8Section 4 – PIVC removal PAGEREF _Toc517766925 \h 10Implementation PAGEREF _Toc517766926 \h 12Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc517766927 \h 12References PAGEREF _Toc517766928 \h 13Definition of Terms PAGEREF _Toc517766929 \h 15Search Terms PAGEREF _Toc517766930 \h 16PurposeThe purpose of this Clinical Procedure is to outline the safe and effective insertion, management, (including line changes) and removal of a Peripheral Intravenous Cannula (PIVC) in people being cared for under the direction of Canberra Hospital and Health Services (CHHS).Back to Table of ContentsScopeAlertsUnder no circumstances, are nurses of any experience, in any division, permitted to insert external jugular access cannulas.PIVC insertion is a Standard Aseptic Technique procedure. Standard Aseptic non touch technique can be performed by experienced staff without touching key areas (i.e. insertion site). If staff do not feel confident to complete the procedure without touching these areas, then sterile gloves must be used. Please refer to CHHS Standard Operating Procedure (SOP), Aseptic Non Touch Technique CHHS14/011.If a PIVC is contaminated at any stage during insertion discard it and use a new PIVC.Where the PIVC has been inserted in an emergency situation where aseptic technique cannot be assured, the cannula must be replaced within 24 hours, in order to prevent infection. If a patient arrives on the ward/unit from another clinical area or facility without clear documentation or information of dating plus/minus time of the PIVC insertion, then the undated PIVC must be removed and replaced.? If however, the receiving clinician can clearly determine from the patient or the patient’s documentation when the PIVC was inserted then a date plus/minus the time should be noted on the PIVC dressing.? The PIVC should under no circumstances be left in without a date plus/minus a timeAll other PIVC must be replaced WITHIN 72 hours, or earlier when there are local or systemic signs of inflammation/infection.ExceptionsPaediatrics – the line remains in until no longer required, unless there are signs of inflammation/infection.Life threatening situations where a PIVC older than 72 hours is insitu and functional and alternative appropriate access has not yet been inserted. The reason for retaining a PIVC beyond 72 hours must be clearly documented in the patient’s medical records.For patients requiring a PIVC for ongoing treatment or management e.g. IV Antibiotics, fluid resuscitation, DO NOT REMOVE the existing PIVC until a new one is successfully sited. In the situation where IV access is difficult, a decision regarding alternative IV access should be made, taking into account urgency and requirement of access. This may include:Switching to oral therapy.A more experienced clinician attempting further PIVC insertions.Team consideration of an alternative IV access, e.g. peripherally inserted central line, central venous line.Back to Table of ContentsScopeThis guideline applies to the following professionals at CHHS:Medical officersRegistered Nurses/Midwives working within their scope of practiceEnrolled Nurses working within their scope of practiceStudents under direct supervision Radiographers who have completed:Administration of Iodinated Contrast Media (eLearning-2017)Aseptic Technique (el-2016-V4)Competency Assessment: Flushing of PIVC’s and administration of contrast media.PIVC insertion may only be performed by staff that have completed appropriate IV cannulation training and credentialing.Back to Table of ContentsSection 1 – Site selection and insertion of PIVCEquipmentDressing trolleyIV starter pack plus alcohol-chlorhexidine 2% swabs or basic dressing pack plus Alcohol chlorhexidine 2% swabs and occlusive transparent film dressing. For patients with a history of chlorhexidine sensitivity/allergy, use:5% alcohol-based povidone-iodine swab≥70% alcohol10% aqueous povidone-iodine (suitable for patients in whom alcohol is contraindicated) Infusion device (safety cannula)Needle less connection valve, safesite or caresite or Extension set with Needleless connection valve or safevalve Syringe 5mlDrawing up needleSodium chloride 0.9% ampoule or Pre filled Sodium chloride 0.9% (0.9% NaCl)IV giving set (if required)Infusion pump or Syringe driver (if required)TourniquetTape for securement of giving setClean gloves or sterile gloves (decision dependent on skill level)Safety goggles or protective face shieldUnderpadLocal anaesthetic if required (note this is not mandatory)Syringe 2ml with 25g needle if giving local anaesthetic Alcohol based hand rub (ABHR).ProcedureStaff must consult the Medical Officer responsible for the patient’s care before insertion to ensure that a PIVC is required, alternatives should be considered and the benefits of PIVC insertion should outweigh the risks.When repeated or prolonged administration of chemical irritants, such as potassium chloride or vancomycin is required, central venous access should be considered, to avoid peripheral vein damage.When selecting a PIVC, ensure that it is equipped with safety engineered device with sharps injury protection. The size of the PIVC should be determined by the intended use (e.g. blood and blood products, drug therapy, hydration etc), the condition of the patient’s veins, likely length of time PIVC is expected to remain in situ and the insertion site.The PIVC should be the shortest and smallest gauge that can meet the anticipated clinical need (i.e. operating theatre, trauma, labour) to ensure optimal flow. The staff member should wash their hands or apply ABHR.Explain the procedure to the patient and obtain informed verbal consent, if appropriate, as per CHHS SOP, Consent and Treatment, DGD12-044.Conduct positive patient identification procedure as per CHHS Clinical Procedure, Patient Identification and Procedure Matching, CHHS14/052.Check the patient’s history for bleeding disorders, medications (e.g. warfarin, aspirin) and allergies, including whether the patient has allergies to skin antiseptics (e.g. chlorhexidine or iodine) or dressing materials.Check for previous difficulties with cannulation and/or IV therapy.Ensure privacy.Wash hands or apply ABHR.Set up, prepare, assemble and open equipment.Don protective eyewear.Position patient comfortably, supporting proposed area of insertion. Place the underpad as required.Apply tourniquet, select vein then release tourniquet.Select the most appropriate vein for insertion of the PIVC. Points to consider include: Patient’s activity levelSize and condition of patient’s veinsIndication for PIVC and expected duration of PIVCPosition of patient during any planned procedure(s)Use non-dominant forearm if practicalUse basilic or cephalic veins on the posterior (dorsal) forearm if possibleThe metacarpal veins on the dorsum of the hand are easier to visualise but are more liable to clot, difficult to stabilise, and prone to vessel damageIn patients with chronic renal failure, the use of the anterior (ventral) forearm veins (especially the cephalic vein) should be avoided, as these may be required for fistula formation for dialysis.Avoid the use of veins in the following sites:Areas of flexion, e.g. antecubital fossa, or bony prominences Vein easily damagedUncomfortableAreas below previous cannulation site Vein may be damagedBruised or phlebitic areas Poor venous return Pieces of clot can be dislodged into the systemA limb with an arteriovenous fistulae or shuntMay compromise haemodialysis accessAn arm on the same side as a previous lymph node dissection, mastectomy or affected by cerebrovascular accident Poor venous and/or lymphatic returnAn infected limb e.g. with cellulitisA limb with a peripherally inserted central catheter (PICC) or implanted venous access device (port-a-cath)Lower limbs (with the exception of infants)Risk of deep vein thrombosis Limits access, patient comfort and mobility.Prepare venepuncture site as required e.g. remove hair at the insertion site (prior to antiseptic application) if necessary, using clippers to improve adherence of the dressing. Clean the skin with neutral soap and water if the insertion site is visibly dirty.Wash hands or apply ABHR.Don gloves, sterile or non sterile according to skill level.Place sterile towel under the selected area.Clean insertion site and surrounding area using a single-use alcohol-based chlorhexidine gluconate swabs (>0.5% chlorhexidine in >70% isopropyl alcohol) swab or other appropriate cleanser if the patient has a chlorhexidine allergy (see equipment list). Apply antiseptic to cover an area of approximately 5 x 5cm in a circular motion with light friction, and allow the skin to air-dry (do not wipe, fan or blot dry the area). Allow at least 30 seconds to dry.Reapply tourniquet, using sterile gauze or with use of an assistant.If required, inject local anaesthetic intra dermally, beside the elected IV site creating a small bleb on the skin. Do not puncture vein when anaesthetising the skin. Draw back on syringe to identify placement ensuring you are not giving intravenous lignocaine.Insert cannula ensuring vein is punctured (visualising ‘flashback’ at the hub of the cannula).Advance plastic cannula and withdraw the stylet. If the PIVC fails to enter vein, do not attempt to reintroduce the stylet into the insitu PIVC. Remove entire device and commence again with a new PIVC and a new IV starter kit if sterility of the kit has been breached. Release tourniquet, attach needleless injection cap or extension set with needleless injection cap to the hub of the cannula and flush cannula with 0.9% NaCl to confirm placement.Secure the IV cannula with Steristrip, over the hub of the cannula and occlusive transparent dressing.Clearly record the date plus/minus a time of insertion of the PIVC on the tape or occlusive transparent dressing Insertion site should remain visible at all times.As soon as possible after the insertion of the PIVC, document (by use of the sticker supplied in the IV starter kit) the date, time, site and size of cannula in the patient’s clinical records and nursing care plan.A maximum of two attempts at PIVC insertion is permitted; following two failed attempts, consult a more experienced clinician. If a more experienced clinician has made two attempts, the clinician is to decide whether they continue attempting to insert the PIVC, or whether an alternate IV access should be considered.Back to Table of Contents Section 2 – PIVC post insertion care and managementEquipmentSterile basic dressing packAlcoholic chlorhexidine 2% swabsOcclusive transparent dressingSteristripsSplint and bandage or elasticised net, if requiredUnderpadDisposable glovesSterile glovesProtective goggles or protective face shieldABHR1 x 10ml ampoules 0.9% NaCl for injectionKidney dishSyringe 10ml x 1 and drawing up needle or Pre filled 0.9% NaCl syringes70% alcohol swabs.Procedure ObservationThe PIVC insertion site must be observed and documented in the nursing care plan and clinical notes each shift and/or whenever the PIVC is accessed for IV medication. The site should be checked to ensure the PIVC site is phlebitis or infection free, therapy has not infiltrated the tissues, the site is clean, dry and the dressing is intact. Explain the procedure to the patient and ensure privacy.Wash hands or apply ABHR.Observe the dressing ensuring that the dressing is dry and intact.Palpate the insertion site for tenderness; ask the patient if it is painful.Check that the date of insertion of the PIVC is legible on the dressing and when the PIVC requires changing.Observe for any signs of infiltration, extravasion, inflammation, swelling and redness before and after access and/or each shift.If there are any signs of adverse reactions, e.g. phlebitis, infiltration, pain, tenderness, the PIVC needs to be removed and reported to the medical officer. The initiation of the removal of the PIVC is by a registered nurse or medical officer only.Document in the patient’s clinical record the observations of the PIVC site every shift. Medical staff are to review the requirement for the PIVC at least daily and document in the clinical record the indication for the ongoing use of the PIVC (e.g. continue IV fluids or IV antibiotics) or requirement to have the PIVC removed.Redress the PIVC site if required. Redressing the siteThe PIVC site should be redressed if the dressing becomes soiled, damp or loose.If the site needs to be redressed, explain the procedure to the patient and ensure privacy.Wash hands or apply ABHR. Don gloves and protective goggles.Prepare equipment.Wash hands or apply ABHR.Position the patient comfortably. Support the proposed site.Remove and discard the soiled dressing.Observe the PIVC site for signs of inflammation, infection or infiltration. Document redressing of cannula, with date and time in patients clinical notes and nursing care planRemove the PIVC if these conditions are apparent, report to the medical officer and follow Section 3; step 12 of this procedure.Wash hands or apply ABHR.Secure the IV cannula with Steristrip, over the hub of the cannula and occlusive transparent dressing.Clearly record the date and time of insertion of the PIVC on the tape or occlusive transparent dressing and document the date, time, site and size of the cannula in the patient’s clinical records and nursing care plan. The insertion site should remain visible at all times.Flushing of a PIVCFlushing of PIVC in situ maintains PIVC patency, minimises adverse reactions and prevents thrombus formation.Flushing of a PIVC must be performed for the following:Pre and post administration of routine intravenous therapy including chemotherapyPre and post medication administrationPre and post routine blood administration and/or blood samplingPrescribed order from a medical officer6th hourly to keep the vein patent. When preparing for flushing of a PIVC, collect equipment and place in clean kidney dish.Don protective goggles.Wash hands or apply ABHR.Don gloves.Draw 0.9% NaCl solution into 10ml syringe using drawing up needle (label as per National Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines as applicable) or use pre filled 0.9% NaCl syringe.Swab needleless injection valves vigorously for 10 seconds with an 70% alcohol swab and allow to dry (30-60 seconds).Check PIVC site for signs of infiltration and /or phlebitis or infection. If present remove the PIVC and arrange for insertion of a new PIVC (refer to section 1).Slowly inject the 0.9% NaCl to flush the PIVC.If the patient experiences pain or tenderness, remove and resite PIVC as per Section 1.Back to Table of ContentsSection 3 – PIVC Administration Sets (changing and frequency)This Section describes the process and frequency for changing administration sets on Peripheral intravenous cannula (PIVC). IV administration sets include both the IV line and any additional attachments such as 3-way luer locks, Y connections and extension tubing that may be added.Line UseFrequency of line changesStandard fluids used continuously and not disconnected Every 72 hours Used to infuse blood and blood products When transfusion is complete or every 12 hours Lipid containing substances (including TPN)Every 24 hoursNeutropenic patientsEvery 24 hours (daily)Main lines with additivesEvery 24 hoursSide lines and syringe lines for intermittent medications, e.g. antibioticsSingle usePropofolEvery 12 hours or when the vial is changedNOTE: Changing of an Intravenous Line is a STANDARD Aseptic Non Touch Technique procedure.When resiting a PIVC the administration set and all additional attachments, fluids etc. must be changed at the same time. IV tubing sets should not be disconnected for routine care, when unavoidable and tubing sets have been disconnected, replace the entire IV tubing.Best practice states that once disconnected IV tubing should not be reconnected. However a health care professional can risk assess the situation in case of urgent therapy.EquipmentIV administration set(s)IV fluids as ordered70% alcohol or 70% alcohol and 2% chlorhexidine extra gauze as necessaryclean glovesProcedureConfirm patient identity, select prescribed fluid and second check with authorised personal. Explain the procedure to the patient, gaining verbal consent if appropriate and ensure patient privacy.Wash hands or apply Alcohol Based Hand Rub (ABHR).Using aseptic non- touch technique assemble equipment, prime lines including all associated connections with IV fluids, ensuring no air is present within the administration set and close clamp. Hang newly primed administration set and fluid on an infusion stand. Wash hands or apply ABHR.Don clean gloves- STANDARD Aseptic Non Touch Technique (ANTT).Clean needleless injection cap vigorously with Chlorhexidine 2% alcohol 70% swab for 10 seconds, allow to drying for 30 seconds.Using ANTT, attach IV giving set to needleless injection cap. Open the clamp to the patient; ensure flow and set rate of infusion.Discard equipment and remove gloves.Wash hands or apply ABHR.Ensure that all lines are labelled with the date of commencement of infusion and the type of infusion and document in clinical notes. Back to Table of ContentsSection 4 – PIVC removalEquipmentGauze swab or occlusive transparent dressing or Injection site pressure padSafety gogglesGlovesUnderpadSpecimen container, if requiredSterile scissors if required if cutting tip off after removal of the PIVCABHR.ProcedurePIVC are to be removed and/or replaced: as soon as they are no longer clinically required ORwhen there are signs of adverse reactions or inflammation/infection/infiltration ORwithin 24 hours for PIVC inserted in emergency situations or by ambulance officers ORwithin 72 hours (with the exception of paediatric patients or adults with life threatening situations where alternate IV access is not available). If ongoing IV access is required, a replacement PIVC should be in situ prior to removal of the existing PIVC.If a patient is admitted with a cannula inserted by paramedics/ambulance officers or from another institution and it is not labelled, or the date of insertion is not documented, the cannula must either be removed or:Dated, if the insertion date is known.Have the words ‘ambulance’ or other similar/appropriate written on the dressing to clearly identify it including current date and timeWhen removing PIVCs, explain the procedure to the patient and ensure privacy.Wash hands or apply ABHR.Don gloves and protective goggles.Prepare equipment.Cease the intravenous therapy if in progress.Loosen the occlusive dressing and tapes use adhesive remove wipes for fragile skin or as required.Grasp the hub firmly and slowly withdraw the PIVC and check that the PIVC is complete on removal. Immediately apply firm pressure to the PIVC site with a gauze swab or injection site pad.Apply pressure to the site until bleeding ceases.Inspect the PIVC site for signs of inflammation or infection.If PIVC site is suspected of being infected cut the tip of the cannula off with sterile scissors and send to pathology in a specimen container labelled with the patient’s details and a pathology request form for analysis.Observe PIVC site for ooze.If required cover the site with either gauze and adhesive tape, or injection site pressure pad.If intravenous fluids were in progress up to the time of the PIVC removal, calculate the volume of fluid and adjust the patient’s intake in the patient’s fluid balance chart.Document in the patient’s clinical records that the PIVC has been removed.Document in the patient’s clinical records if the tip of the PIVC has been sent to pathology.Back to Table of Contents Implementation All staff emailNews item on the HealthHUB Information on PIVC insertion and management policy to be provided to Quality Officers for display on Quality Boards.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationNational StandardsStandard 1, Governance for Safety and Quality in Health Service OrganisationsStandard 3: Preventing and Controlling Health Care Infections PoliciesACT Government Health Directorate Nursing and Midwifery Continuing Competence Policy, DGD12-050CHHS Clinical Policy, Medication Handling PolicyProceduresACT Government Health Directorate Standard Operating Procedure (SOP), Patient Identification: Pathology Specimen Labelling, DGD12-024ACT Government Health Directorate SOP, Consent for a Child or Young Person, DGD12-044 ACT Government Health Directorate SOP, Incident Management, DGD12-047 ACT Government Health Directorate SOP, Significant Incidents, DGD12-047CHHS Clinical Procedure, Healthcare Associated Infections, CHHS15/072CHHS SOP, Aseptic Non Touch Technique Procedure, CHHS14/011CHHS SOP, Personal Protective Equipment, CHHS12/251CHHS Clinical Procedure, Clinical Handover, CHHS15/069CHHS SOP, Venepuncture Blood Specimen Collection, CHHS12/178 CHHS Clinical Procedure, Patient Identification and Procedure Matching, CHHS14/052CHHS SOP, Clinical Record Documentation, DGD12-048CHHS SOP, Consent and Treatment, DGD12-044CHHS SOP, Pathology Requests and Specimens TCH11:012.Guidelines Australian Commission on Safety and Quality in Health Care, National Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines, February 2012.LegislationACT OH&S Act 1989 (republication date: 25 October 2007)Back to Table of ContentsReferencesAustralian Commission on Safety and Quality in Healthcare (ACSQHC) (September 2011). National Safety and Quality Health Services Standards, ACSQHC, Sydney. Austin Health Clinical Procedure, Insertion, Care and Maintenance of Peripheral Intravenous Cannula Document No: 10987, Version No: 1.4, 2013.BBraun Cannulation Theory 2011.BBraun Introcan Cannula 2011.Center for Disease Control and Prevention, U.S. Department of Health and Human Services. 2011 guidelines for the prevention of intravascular catheter-related infections. Available at: Collignon, PJ, Kimber FJ, Beckingham, WD and Roberts, JL. Prevention of peripheral intravenous catheter-related bloodstream infections: the need for routine replacement. Med J Aust 2013; 199(11):750-751.Collignon, PJ et al. Intravascular catheter bloodstream infections: an effective and sustained hospital-wide prevention program over 8 years. Med J Aust 2007; 187(10):551-554.Hand Hygiene Australia. Accessed at: Infection Control Special Interest Group: Talk: Peripheral intravenous cannulae. Available at: Briggs. (2008). Management of Peripheral Intravascular Devices. Best Practice, 12 (5), Pages 1-6.Smith, S.F., Duell, D. J., Martin, B. C., (2004) Clinical Nursing skills-Basic to Advanced, 6th edition, Pearson Education, New Jersey, Chapter 20 Specimen Collection, pages 641-642Stuart, RL et al. Peripheral intravenous catheter-associated Staphylococcus aureus bacteraemia: more than 5 years of prospective data from two tertiary health services. Med J Aust 2013; 198(10): 551-553. Trinh TT et al. Peripheral venous catheter-related Staphylococcus aureus bacteraemia. Infect Control Hosp Epidemiol. 2011 Jul; 32(7); 735Waitt C, et al. Review: Intravenous Therapy. Postgrad Med J 2004; 80:1-6.Webster J, Osborne S, Rickard C, et al. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2010;(3):CD007798Back to Table of ContentsDefinition of Terms Antiseptics Antimicrobial substances that are applied to the skin to reduce the number of micro-organisms. Examples include topical alcohols, chlorhexidine, triclosan and iodine.Alcohol-based hand rub (ABHR) An alcohol-containing preparation designed for application to the hands in order to reduce the number of viable micro-organisms with maximum efficacy and speed.Aseptic technique An aseptic technique aims to prevent microorganisms on hands, surfaces and equipment from being introduced to susceptible sites.Attempt Each effort at placing a PIVC at one site.Clinician For the purpose of this Guideline a clinician is defined as a medical practitioner registered nurse or midwife, endorsed enrolled nurse, assistant in nursing, qualified paramedic, radiographer, anaesthetic technician, pathology collector or student in any of those petent/Trained For the purpose of the guideline, a competent clinician is one who hascompleted a training program in the insertion of PIVCs or who is in, or has completed, a specialist medical training programEscalation An inexperienced clinician who fails to cannulate a vein after two attempts should escalate the procedure to an experienced clinician.Experienced clinician A clinician who has completed a training program in the insertion ofPIVCs or who is in, or has completed, a specialist medical training program and has inserted a considerable number of PIVCs. Experienced clinicians are not necessarily more senior clinicians; they may be colleagues such as a Registered Nurse/Midwife or a Junior Resident Medical Officer.Inexperienced clinicianA clinician who has completed a training program but is still gaining clinical experience and confidence in the insertion of PIVCs.Peripheral Intravenous Cannula (PIVC) a device that is designed to be inserted into and remain within a peripheral vein (excludes peripherally inserted central line catheters).Personal Protective Equipment (PPE)Refers to a variety of protective barriers used alone, or in combination, to protect mucous membranes, skin, and clothing from contact with recognised and unrecognised sources of infectious agents in healthcare settings.Safety engineered deviceAn invasive device that has been designed with built-in safety features that reduce the risk of injury. Examples include devices such as syringes with guards, sliding sheaths, shielded, blunting or retracting needles, blunt suture needles and surgical blades with protective covers.Back to Table of ContentsSearch Terms PIVC, Cannula, Peripheral Intravenous Cannula, IV cannula, Intravenous Cannula, Intravenous Cannula management, Intravenous Cannula insertion, Intravenous Cannula removalBack to Table of ContentsDisclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved By06/04/2017Addition of Section 3CHHS-PC Chair21/06/2017Information pertaining to Radiographers to the scope sectionCHHS-PC06/10/2017Additional dot point added to section 3CET Policy Team26/06/2018Additions to alerts and section 1 regarding documentation requirements including date and time.Executive Director, CSS and CHHS Policy Committee Chair ................
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