Minnesota Hospital Association
Hennepin Healthcare SystemPolicy Title: Vascular Access Insertion, Use, and ManagementPolicy Sponsor: Infection PreventionReview Body(s): Infection Prevention Committee, Policy CommitteeFinal Approval Body: Medical Executive CommitteeOriginal Approval Date: 2003Last Reviewed/ Revised: 04/22/2014POLICYThis policy represents best practices for the use of vascular access lines and is the minimum standard of care for all patients at HCMC to reduce the risk of complications, including but not limited to, infections. Table of ContentsPageDefinitions1-2Indications for Use2Orders2-3General Principles3Central Line Insertion3-4Central Line Replacement4-5Use, Maintenance, and Access5-6Site Care and Dressing6-7Culturing for Suspected Infection7Complication7Removal7-8Patient Education8Training and Competency - Nursing8-9Training and Competency - Provider9Monitoring9References, Related Policies and Procedures9-10Central Line Insertion ChecklistSupporting DocumentDefinitionsAPP: Advanced Practice ProviderCentral Venous Catheter: Are non-tunneled lines such as a PICC, IJ, SCV, Quinton, cordis, Swan-ganz, femoral venous catheter, cooling catheter, temporary dialysis catheter, UAC, UVC; or tunneled such as a Hickman, Broviac,or GroshongThe type of line does not determine if it is a central line, it is where the line terminates. A central line is any intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring. The following are considered great vessels: aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, common iliac veins, femoral veins, and the umbilical artery/vein in neonates. CHG: Chlorhexidine gluconate: an antiseptic frequently combined with 70% alcohol used to prepare the skin in persons >2months of age.CLABSI: Central Line Associated Blood Stream InfectionHD: HemodialysisIJ: Internal Jugular LIP: Licensed Independent PractitionerMosby: HCMC’s online nursing procedure manualNon-Sterile Line: Any central line placed with breaks in the sterile procedure when the sterility is unable to be re-established PICC: Peripherally inserted central catheter for which the tip resides in the lower 1/3 of the superior vena cava or right atrium (SVC/RA junction). In infants, the PICC may end in the inferior vena cava. SCV: Subclavian Stop the Line: A complete halt in the procedure when any part of the process is not followed and/or a discrepancy is discovered. The procedure will not continue until all the steps of the process are completed and any discrepancy resolved. (See Universal Protocol Policy # 009582)TKO: To keep openTPN: Total parenteral nutritionUAC: Umbilical Artery CatheterUVC: Umbilical Venous CatheterPROCEDURESIndications for UseClinical conditions warranting placement or continuation of a central access include the following:Need for multiple access portsTo administer large amounts of fluid quicklyNeed for safe delivery of medications/solutionsVasopressor administration Central venous monitoringMonitoring induced hypothermiaDialysis Orders All vascular lines shall have an order placed defining location, use of catheter, and maintenance.All temporary IJ, SCV, and PICC lines require catheter termination (site) documentation as soon as safely possible.Patients admitted with existing lines (tunneled or non-tunneled): Place an order for IV team consult prior to use (not including NICU patients)If line is in use upon arrival, verify for patency, continued use, and request IV team consultOrders must be placed by the renal team for use of dialysis catheters for fluid administration or blood draws in non-emergent situations.Daily assess the need for all central lines. Place an order for removal when clinically indicated.General PrinciplesPerform hand hygiene either by washing hands with antimicrobial soap (e.g. 2% chlorhexidine gluconate) or with alcohol based hand sanitizer before and after palpating and examining insertion sites, as well as before inserting, accessing, replacing, or dressing an intravascular catheter. Skin preparation of patient prior to line insertionIf patient’s skin is visibly soiled, clean with soap and water or CHG bathing cloth prior to prepping.All patients with a central line, shall have daily bathing with CHG (prefer CHG bathing cloth) unless use is contraindicated by allergy or age <35 weeks (gestational age) AND <2 weeks of life.Central Line InsertionSelection of insertion siteSubclavian lowest risk of infection-but higher procedural risk Internal JugularFemoralTo be used only in emergent conditions and removed within 2 days of placement if other sites available.Cooling catheters used for the hypothermia protocol may be inserted in the femoral vein until the patient has been rewarmed.Insertion Checklist A dedicated independent observer is required to be at the bedside during the insertion of all temporary, non-tunneled central lines.The observer can be an MD/DO, RN, APP, or Medical Student who has received training in the monitoring of safe insertion practices.It is the responsibility of the inserter to secure the independent observer prior to beginning the procedure.In the event of a medical emergency where adherence to the checklist cannot be assured, label the line as non-sterilely placed using a yellow “change in 48 hour sticker”.The observer will monitor for the safe insertion of the central line and use the Central Line Insertion Checklist employing the Stop the Line process of the Universal Protocol.The observer will immediately notify the operator of any deviation from the mandatory steps in the checklist, stop the procedure as necessary, and assure compliance before the procedure can proceed.The checklist observer shall contact the attending physician if concerns arise related to insertion. Use maximum sterile barrier precautions including the use of a cap, mask, sterile gown, sterile gloves, and a large sterile drape for the insertion of all central catheters, PICC lines, pulmonary artery catheters, hemodialysis catheters, guidewire exchanges, and umbilical catheters. For the insertion of peripheral arterial lines, a minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used.Use a new set of sterile gloves before handling the new catheter when guidewire exchanges are performed. When using topical anesthetics, apply prior to cleansing the site with antiseptic. Cutaneous antisepsisThe antiseptic of choice to prep the skin before insertion of an intravascular catheter is a 2% chlorhexidine gluconate (CHG) / 70% alcohol (e.g. Chlorascrub swab). Use repeated back and forth strokes with the CHG for 30 seconds (2 minutes for wet areas such as the groin) and then let dry for at least 30 seconds. If unable to use CHG because of patient sensitivity or age <35 weeks (gestational age) AND <2 weeks of life, thoroughly cleanse site with 70% isopropyl alcohol, follow with 10% povidone iodine, and allow to dry for at least 2 minutes.Ultrasound guidance is recommended for all central line placements.A CXR is required to verify placement upon completion of catheter insertion for all subclavian, jugular, UAC, UVC, and PICC lines. Reviewing the CXR and appropriate follow-up is the responsibility of the physician/RN that placed the catheter. New technologies and products related to venous access must be approved by the Supply Chain product committee prior purchasing for use.Central Line Replacement Line replacement should be at a new site.Replace any short term catheter if purulent drainage (possibly indicating infection) is present at insertion site. Do not routinely replace central venous or arterial catheters solely for the purpose of reducing the incidence of infection. However, use clinical judgment to determine when to remove a centrally inserted catheter that could be a source of an infection. Do not routinely replace catheters in patients whose only indication of infection is fever.Emergently placed lines When catheters are inserted during a medical emergency in which adherence to aseptic technique cannot be ensured, the replacement of the catheter within 48 hours is the responsibility of the attending physician. Non-sterilely placed central lines must be tagged by the inserter with a yellow “change in 48 hour sticker”.UVC’s placed emergently in the delivery room should be replaced when the infant is stabilized in the ICU. Cooling catheters arePlaced per Induced Hypothermia Protocols.Removed promptly once patient is warmed. Lines placed under unknown conditions should be changed within 48 hours, when alternative site access is available. All lines present on admission shall be evaluated. If sterile placement/maintenance is questionable, best practice would be to change the line within 48 hours when an alternate access site is available. All temporary HD catheters should be changed to a tunneled catheter within 14 days of use when patient condition warrants ongoing need for dialysis access.Lines with compromised dressing integrity Consider replacing central venous access when 2 or more unplanned dressing changes have occurred between the normally scheduled dressing schedule.Rewiring Do not use guidewire exchanges to replace a non-tunneled catheter suspected of infection.Central venous lines may be changed over a wire if the patient is febrile and it is unclear whether the line is the source.For occlusion or mechanical failure, it is appropriate when the central venous access is a continued necessity.Consider placement of a tunneled catheter or PICC line in place of the IJ or SCV when the need for the central access is:Expected to extend beyond the ICU stayExpected to extend beyond hospital stayExpected during a long term NICU stayUse, Maintenance and Access Continuation of a central access must be assessed/reassessed at a minimum of every 24 hours. AccessAlways scrub the hubs on the IV system with CHG swab (preferred) or 70% isopropyl alcohol for 10 seconds before entering. Allow the antiseptic to dry for 20 seconds prior to access. Limit the number of times the line is entered if possible. All stopcocks must be capped with sterile caps immediately when not in use. See Venous Access Grid or NICU Venous Access Grid for other access standardsDialysis line access: Due to the higher risk of infection with temporary dialysis lines, obtain an order from renal team prior to accessing dialysis catheters for IV use or blood draws in non-emergent situations. Only nurses who have been deemed competent may draw from these catheters. Tubing Changes IV therapy will be initiated within 1 hour of spiking the IV bag with tubing. If the setup is pre-primed for a prospective patient, it must be used within 1 hour of spiking and the IV bag and tubing must be labeled with the date, time and initials of the person setting it up. Exception: “hazardous to handle” IV medications which are prepared in the Pharmacy Clean Room with primed tubing. USP/ASHP/NIOSH support both the preparation of these toxic items in a contained environment (priming in the clean room to decreases exposure to staff and the environment) and 24 hour to 7 day ?stability following manipulation in the clean room, depending on the product.Change all tubing at the time of a line change/replacement Label all IV tubing with the time of change AND when they are due to be changed using the HCMC IV change labels. Needleless connectorsAttach needleless connectors to all stopcocks and arterial lines (includes central lines, dialysis, PICC, tunneled and implanted ports).Place Tego needleless connectors on all hemodialysis lines.Change connectors with the tubing and as needed.Flush needleless connectors as needed to clear blood. If blood cannot be cleared, then change connector.SOLUTION AND TUBING CHANGE TIMESInfusion TypeExpiration/Change Time (in hours)Bag/Soln*Tubing and 2dary setsOtherTPN24 hr96 hrDesignate one port exclusively for parenteral nutrition with multilumen cathetersIV Lipids (fat emulsions)12 hr24 hrDirpirvan (Propofol)12 hr12 hrWhen Diprivan is transferred to another syringe or container, it must be labeled with an expiration time of 6 hours. The responsible nurse must discard it after 6 hours regardless of when that time falls within the nurse’s shift. Blood and Blood Productsw/each unit4 hours or after 2 units whichever occurs 1stIV Ativan continuous infusion24 hrFiltered pump tubing should be used with diluted Ativan due to the possibility of precipitationTKO96 hr96 hrContinuous96 hr96 hrIntermittent24 hr24 hrSee exception in hazardous to handleArt Line and Pulmonary Art Cath96 hr96 hr (and transducer)Including continuous-flush device and flush solution*change at time interval or upon new line/line replacementSite Care and DressingAssess all intravascular device insertion sites a minimum of every shift for signs of infiltration, phlebitis or infections and document observation. Infiltration: swelling, coolness, painPhlebitis: redness, inflammation, swelling, painInfection: redness, drainage or pus at the exit site, painDo not submerge the catheter under water. Showering is permitted only if the catheter and connecting device (e.g., injection cap) can be covered with an impermeable cover to prevent moisture on the catheter and connecting device. Dressing change frequencyDressings shall be changed immediately if they become loose, soiled and/or condensation builds up under the dressing.Gauze dressings are to be changed at a minimum every 2 days.Transparent dressings are to be changed at a minimum of every 7 days.Dressings are not applied to umbilical catheters.In pediatric patients, dressing changes may vary when the risk for dislodging the catheter outweigh the benefit of changing the dressing.All central lines, excluding ports, should have a Biopatch placed unless use is contraindicated by allergy or age <35 weeks (gestational age) AND <2 weeks of life.Antimicrobial ointment or creamDo not routinely apply to non- dialysis lines.Antimicrobial ointments can be used for hemodialysis catheter insertion sites. Label dressing with date change AND change due date.Dressing disruption management/notification Notify the provider when 2 or more unplanned dressing changes have occurred between the normal dressing schedules for consideration of line replacement. Refer to Mosby for complete dressing change procedure. Document site care, dressing change, condition of the site and any needle change in EPIC Doc Flowsheets.Blood cultures for suspected line related sepsisUse clinical judgment prior to the collection of cultures. Low grade temps (e.g < 38.6) may not always require blood cultures in absence of clinical signs of sepsis. If blood cultures have already been obtained within last 24 hours for fever workup, do not repeat unless there is clinical deterioration. Paired blood cultures to be drawn at 2 peripheral sites. If peripheral site are not available, line culture may be drawn after port prepped with CHG for 10 seconds and allowed to dry for 20 seconds. Document that the culture was drawn from the line. ComplicationsAppropriate monitoring for complications will be part of the daily documentation. RemovalAssess patient and document reason for continuation at minimum every 24 hours. Remove at first clinical opportunity.Removal processRefer to Mosby for complete procedure.Replace any short term catheter if purulent drainage (possibly indicating infection) is present at insertion site. Do not routinely replace central venous or arterial catheters solely for the purpose of reducing the incidence of infection. However, use clinical judgment to determine when to remove a centrally inserted catheter that could be a source of an infection. Do not routinely replace catheters in patients whose only indication of infection is fever.Do not use guidewire exchanges to replace a non-tunneled catheter suspected of infection.Central venous lines may be changed over a wire if the patient is febrile and it is unclear whether the line is the source. Replace all central catheters if the patient is hemodynamically unstable and a catheter-related blood stream or insertion site infection is suspected. Remove umbilical catheters as soon as possible when no longer needed or when vascular insufficiency is likely. Limit use of umbilical artery for central line access to < 5 days whenever clinically possible. Umbilical vein should only be used for central line access for < 14 days. Once an MD orders a central line to be discontinued, RN’s that have demonstrated competency may remove PICC, temporary subclavian and internal/external jugular central catheters. This procedure is not intended for infants and neonates.Patient EducationStaff shall provide education to the patient for their role in prevention a CLABSI such as: Do not touch the line and remind your family and friends not to touch.Report any time the dressing?is not lying flat or is moist.Ask staff to wash their hands or use foam before they touch your line.Watch for staff to use the line safely -?everyone should clean the port each and every time before entering the line with a syringe or other tube.Ask staff every day if you still need the line.Let your nurse or doctor know if the area feels sore or you notice redness.If you need to go home with your line, you will receive further instruction for home care.Training and Competency - NursingStaff and LIPs who are involved in managing lines shall be educated in infection prevention measures upon hire, annually thereafter and when involvement in these procedures is added to an individual’s job responsibilities. Staff will periodically be assessed for knowledge of adherence to insertion and maintenance best practices. Nursing training and competency requirements for insertion, observation of central line insertion, use, maintenance, and removal (I, O, U, M, and R respectively).Peripheral LinesCentral Lines UnitResponsibilityUnitNon-tunneledTunneledBurn Step downIV Team for I,MUnit for U,RBurn Step downO, U,M,RU,MClinicsI,U,M,RClinicsU,M,RU,MEDI,U,M,REDO,U,M,RU,MInterventional RadiologyI,U,M,RInterventional RadiologyO,U,M,RU,MICU (all)I,U,M,RICU (all)O,U,M,RU,MMed-Surg IV Team for I,MUnit for U,RMed-Surg O,M,RU,MPedsI,U,M,RPedsO,U,M,RU,MPACUI,U,M,RPACUO,U,M,RU,MORManaged by APPORManaged by APPManaged by APPSurgical AdmissionsI,U,M,RSurgical AdmissionsO,U,MU,MSpecialty lines (eg: implanted) require training at the unit level by the users prior to use.IV team training and competencyAll RN staff will complete training and competency for insertion, care and?maintenance of a PIV, Midline catheter, ultrafiltration catheter, PICC 's?with or without ?image guided venipuncture, and act as a clinical?resource? for the identification and management of all Vascular access devices. Training and Competency – Provider Physician and APPs who are involved in managing lines shall be educated in infection prevention measures upon hire, annually thereafter and when involvement in these procedures is added to an individual’s job responsibilities. Staff will periodically be assessed for knowledge of adherence to insertion and maintenance best practices. ResidentsAll residents must have successfully placed a simulated central line and Demonstrate competency per the Resident/Fellow Scope of Practice MonitoringOutcome MeasuresAll positive blood cultures are monitored by Infection Prevention. These cultures are reviewed using the Centers for Disease Control National Healthcare Safety Network surveillance definitions for infection. All CLABSI will receive a systems case review. The review will occur within a week of occurrence and will include the involved staff, providers, Performance Measurement and Improvement, and Infection Prevention.Centers for Medicare and Medicaid reportingInfection Prevention reports laboratory confirmed CLABSI to CMS per current reporting requirements.Coding reports all CLABSI meeting CMS Health Care Acquired (HAC) requirements. Process Measures Measurement of best practices required by regulatory bodies (including, but not limited to The Joint Commission) will be monitored by the patient care units and Infection Prevention and reported to Executive Leadership on a routine basis. Examples of best practice include, but are not limited to: education, use of the insertion checklist, hand hygiene, and device utilization. Related Protocols:Induced Hypothermia ProtocolInduced Hypothermia protocol for Brain InjuryRelated Policies:Intravenous Infusions: Standard of CareResident/Fellow Scope of PracticeIntravascular Access: PeripheralMedication Management Selection Policy – Addendum AUniversal Protocol Policy # 009582References: Centers for Disease Control and Prevention. Guideline for the Prevention of Intravascular Catheter-Related Infections. MMWR, 2011;51 (No. RR-10)Infusion Nursing Standards of Practice. The Journal of Infusion Nursing 2011; vol 43, No 1SUSP: United States Pharmacopeia, USP 797ASHP: American Society of Health System PharmacistsStrategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals. Infection Control and Hospital Epidemiology 2008; 29:S22-S30CMS Conditions of ParticipationThe Joint Commission National Patient Safety Goal 7.04.01 IHI Preventing Central Line Infections – How to Guide, 100,000 Lives CampaignDiprivan 1% product insertNational Kidney Foundation KDOQI Guidelines 2000 Staff Education:Patient Education: CLABSI prevention see section 12 and Insertion Checklist ................
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