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1 If viewing a printed copy of this policy, please note it could be expired. Got to to view current policies. Entity: Fairview Pharmacy Services Department: Fairview Home Infusion Manual: Policy and Procedure Manual Category: Home Infusion Subject: Access Device Management, General Policies Department Policy Code: D: PC-5100 Purpose: Fairview Home Infusion qualified staff will be knowledgeable in Access Device Management. Definition: Access Devices refer to a large variety of manufactured devices that can be inserted percutaneously or surgically and are designed to allow for the local or systemic treatment of illnesses via the venous, arterial, enteral, intracavitary, intraspinal and subcutaneous routes. Policy: The following policies address common guidelines to be used for care of many of the access devices. Refer to Attachment I and device specific policies and procedures for additional information. I. Written physician orders for initiation, care and management of the access device shall be documented on the Plan of Care and include: A. Type of device including the name and number of lumens. B. Use of an anesthetic (e.g. Emla or Lidocaine) for insertion of percutaneous catheters, if appropriate and indicated. C. Concentration, amount and frequency of heparin flushing solution, if applicable. D. Amount and frequency of saline flushing solution, if applicable. E. Type and frequency of site care. F. Whether or not the access device may be used for blood drawing, if applicable. G. Whether or not the access device may be repaired, if Page 1 of 19

2 applicable. II. Following receipt of a physician s order, a nurse deemed competent may: A. Remove a non-tunneled central venous catheter. B. Remove catheter sutures (excluding PICC s) C. Insert a different catheter type. D. Insert a catheter, following Nurse Practice Guidelines. E. Perform a catheter repair following manufacturer instructions. F. Perform a catheter exchange for Peripherally Inserted Central Catheters (PICC). III. General guidelines for protection of all catheter types include: A. Never use scissors near a catheter. B. If a needle is used to access the injection cap, never use one longer than 1 to avoid puncturing the catheter. C. Routine clamping of a CVC is necessary when not in use. If the clamp is not part of the catheter, use a smooth-edged clamp over a piece of tape placed on the catheter. Damage may occur if a clamp with teeth is applied to the catheter. EXCEPTION: The Groshong catheter should not be clamped unless the integrity of the valve has been comprised or a catheter repair is being performed. (A clamp must always be available). D. Avoid using acetone solutions or iodine tinctures which can cause silicone to dry and crack. E. 5. When drawing blood from a multi-lumen catheter, the distal lumen should be used. IV. As part of patient/caregiver education, the nurse shall instruct the patient/caregiver in appropriate access device management including catheter site care, injection cap change, flushing and signs/symptoms and management of infected, displaced, damaged or obstructed catheter/port/feeding tube.

3 V. A needleless system shall be utilized in administering all intravenous therapies. VI. All connections in the intravenous system (catheter and tubing) shall be luer lock. VII. Catheter occlusions will be cleared to restore patency with a physician order and protocols with clinical evidence to support the procedure. Procedure: I. Central Venous Catheters Central venous catheters (CVC) are either surgically or percutaneously placed and are catheters whose distal tip is located in the superior vena cava or high right atrium. Veins most appropriate for central venous access are the internal jugular and subclavian veins. When the femoral ein is used for central venous access, correct tip location is the inferior vena cava. A. Non-Tunneled or Percutaneous Short-term percutaneous CVCs inserted directly into the selected vein based on anatomical landmarks. The veins typically used to gain access to the central venous system are the jugular veins and the subclavian vein. 1. Polyurethane is the most commonly used material. 2. Intended for days to several weeks of IV access. 3. Multiple lumen features. 4. In-room or outpatient insertion procedure. 5. For short-term use only. 6. Requires routine sterile dressing changes. 7. Patient self-care difficult due to chest insertion site. B. Tunneled Catheter a catheter designed to have a portion lie within a subcutaneous passage before exiting the body. Tunneled catheters have a Dacron cuff attached, which after insertion, is located within the subcutaneous tunnel. Central venous access with the tunneled catheter is usually accomplished by a percutaneous approach using a Seldinger (over-the-guide wire) technique into the subclavian or internal jugular veins. The point at which the catheter exits the body (exit site) is considerable distance from the actual venous insertion site, thus making it more difficult for microorganisms to reach the venous system. Both tunnel

4 length and proper location of the cuff are important to prevent catheter dislodgment. Exit site sutures placed post insertion to prevent dislodgment of catheter allowing for the Dacron cuff to adhere. Sutures can be removed after 10 days with physicians order. 1. Silastic is most commonly used material. 2. Intended for long-term intermittent, continuous, or daily IV access. 3. The optimal time interval for removal of a central venous catheter is unknown; ongoing and frequent monitoring of site should be performed and documented. 4. May be single or multiple lumen. 5. Sterile dressing changes every seven (7) days and PRN. 6. May be open ended or valved (Groshong). 7. Placement can be done as outpatient surgical procedure. C. Peripherally Inserted Central Catheter (PICC Lines) Catheters inserted into the cephalic or basilic vein in the antecubital fossa. The tip is located in the superior vena cava at the juncture of the right atrium. X-ray verification is needed to verify placement. 1. Intended for long-term intermittent, continuous, or daily IV access. 2. The optimal time interval for removal of a peripherally inserted central catheter is unknown; ongoing and frequent monitoring of site should be performed and documented. 3. May be single of multiple lumen. 4. Sterile dressing changes every seven (7) days and PRN. 5. May be open ended or valved (Groshong). 6. Single lumen Groshong PICC can be repaired externally.

5 7. Placement can be done as outpatient surgical procedure. II. Implanted Ports A totally implanted system consisting of a reservoir which is made of plastic, titanium or stainless steel well with self-sealing silicone septum attached to a radiopaque catheter made of silicone or polyurethane. It is not visible, since the reservoir is implanted as a sterile procedure by a surgeon under the skin in the subcutaneous fascia. May be placed in an artery, epidural/intrathecal space, intrapleural or peritoneal space. P.A.S. Port: - Implanted vascular access device placed in forearm and catheter threaded into the cephalic or basilica vein in the antecubital fossa. The tip is located in the superior vena cava. III. Midline Catheters Catheters placed in the antecubital fossa and threaded 6-8 inches, whose tip remains in the upper arm, not extending past the axilla. Not a central venous catheter. IV therapy administered in this catheter must meet peripheral IV therapy criteria. Therapeutic use 2-4 weeks. IV. Peripheral Venous Catheters or Steel Needles Catheters or needles used to access peripheral veins. Visual length is ¾ - 2 inches. A. Placed for short-term therapy (usually less than seven (7) days. B. Peripheral catheters should not be routinely used for blood draws. C. Site must be changed every hours. V. Subcutaneous Catheters or Needles Devices used for infusion of opioids, deferoxamine, heparin, or hormonal therapy gauge catheters or needles are changed every three (3) days. VI. Intraspinal Catheters/Ports (Epidural or Intrathecal) Device which is usually tunneled through the subcutaneous tissue and whose catheter tip resides in the epidural or intrathecal space. VII. Enteral Access Devices Feeding tubes which are either nasogastric (NG) or nasointestinal (NI) for short-term use and gastrostomy or jejunostomy tubes placed for long-term feedings.

6 Site Care and Dressing Change Dressings shall be changed at established intervals, immediately upon suspected contamination, or when integrity of dressing is compromised. Gauze dressings shall be changed every 48 hours on peripheral and central catheters. Transparent semi-permeable membrane dressings shall be changed at the time of access site rotation or every three (3) to seven (7) days, whichever comes first. BioPatch disk will be used with each dressing change for all patients 2 months of age or older with central IV catheters (excludes implanted ports). Prior to Beginning Procedure A. Wash hands. B. Assemble equipment. C. Don sterile gloves and other PPE. D. Use aseptic technique and observe Standard Precautions throughout procedure. Site Care and Dressing Change A. Remove dressing from VAD insertion site. B. Inspect site and catheter. C. Disinfect catheter-skin junction using antiseptic solution. Using friction, apply antiseptic solution 1. If using alcohol, apply friction for a minimum of 30 seconds. 2. If using chlorhexidine gluconate, use friction according to manufacturer s labeled use and directions. Only one application is necessary. Prepared site will be approximately the size of dressing (i.e., 2 to 4 inches diameter) Allow antiseptic solution to air dry (do not blow or blot dry) Repeat twice as necessary depending on antiseptic solution.

7 Use of Gauze Dressing A. Position sterile gauze over catheter insertion site. B. Seal dressing edges with tape. C. Change dressing every 48 hours. D. Change dressing immediately if integrity is compromised or it there is drainage or moisture. E. Label dressing with initials and date. Note: When transparent semipermeable membrane (TSM) is applied over gauze, it is considered a gauze dressing. Use of Transparent Semipermeable Membrane (TSM) A. Secure wings of catheter in PICC stabilization device if needed. B. Position sterile dressing over insertion site. C. Apply TSM according to manufacturer s labeled use and directions. D. Gently smooth dressing from center toward edge; do not apply excessive tension as skin shearing may result. E. Avoid sealing TSM dressing edges with tape. F. Do not cover TSM with roller bandage. G. Change dressing immediately if integrity is compromised or if there is excessive drainage or moisture. H. Change dressing at the following intervals: For peripheral-short catheter sites: change TSM dressing at time of site rotation For catheter sites other than peripheral-short catheter sites: change TSM dressing every three (3) to seven (7) days. Note: When TSM is applied over gauze, it is considered a gauze dressing and must be changed every 48 hours. I. Label dressing with initials and date. Post-Site Dressing

8 A. Discard used supplies. B. Remove gloves. C. Wash hands. Flushing Flushing is performed to ensure and maintain patency of the catheter, and to prevent mixing of medications and solutions that are incompatible. Flushing with anticoagulant citrate will be performed to maintain catheter patency for patients requiring a Heparin flush who are allergic to heparin. The volume or amount of anticoagulant citrate will be equal to the amount of Heparin used to flush the vascular access device. Routine flushing shall be performed with the following: Administration of blood and blood components. Blood sampling. Administration of incompatible medications or solutions. Administration of medication. Intermittent therapy. When converting from continuous to intermittent therapies. Prior to Beginning Procedure A. Wash hands. B. Assemble equipment. C. Don sterile gloves and other PPE. D. Use aseptic technique and observe Standard Precautions throughout procedure. Flushing A. Follow manufacturer s labeled use and directions for flushing VADs.

9 B. If resistance is met or an absent blood aspirate is noted, the nurse should take further steps to assess patency. The catheter should not be forcibly flushed. C. Disinfect catheter injection or access cap with antiseptic solution. D. With preservative-free 0.9% sodium chloride (USP): Flush to maintain patency of intermittent VADs with closed distal tip and three-position valve. Connect preservative-free 0.9% sodium chloride (USP)- filled syringe to catheter via insertion into prepared injection or access cap. Inject flush solution using the pulse technique. Disconnect syringe from injection or access cap. E. With heparin only: Flush to maintain patency of intermittent VADs. Connect heparin-filled syringe to catheter via insertion into prepared injection or access cap. Inject flush solution using the pulse technique. Disconnect syringe from injection or access cap. F. Using the SASH (Saline-Administration-Saline-Heparin) or SAS (Saline-Administration-Saline) method: Use SASH flushing procedure when heparin is used for flushing. Use SAS flushing procedure when saline is used for flushing. Connect first preservative-free 0.9% sodium chloride (USP)-filled syringe to injection or access cap. Flush with preservative-free 0.9% sodium chloride (USP); remove syringe and discard. Disinfect cap with appropriate antiseptic solution. Connect medication to injection or access cap.

10 Post Flush Administer medication. Disconnect medication from injection or access cap. Disinfect injection or access cap with appropriate antiseptic solution. Connect second preservative-free0.9% sodium chloride (USP)-filled syringe to injection or access cap. Flush with preservative-free 0.9% sodium chloride (USP); remove syringe and discard. If needed for heparin flushing (SASH), disinfect injection or access cap with antiseptic solution. If needed (SASH), connect heparin-filled syringe to injection or access cap. If needed (SASH), inject heparin flush solution using the pulse technique. If used for heparin flushing (SASH), disconnect syringe from injection or access cap and discard. A. Discard used supplies in appropriate receptacles. B. Remove gloves. C. Wash hands. D. Document in patient s permanent medical record. Blood Specimen Collection Blood specimen collection for blood sample assay determination, or therapeutic indications may be drawn: Peripherally via peripheral venipuncture From peripheral vascular access device(s) at the time of insertion From central vascular access device(s) Blood specimens may not be drawn from an infusion administration set or proximal to an existing infusion site. An indwelling peripheral or midline catheter is not routinely used for

11 blood specimen collection. The nurse shall be knowledgeable concerning blood specimen collection technique and practices, including order of the draw. Collaborate with organizational laboratory for confirmation of order of draw and appropriate collection equipment. Prior to Beginning Procedure A. Wash hands. B. Assemble equipment. C. Don gloves. D. Use aseptic technique and observe Standard Precautions throughout blood specimen collection procedure. From Peripheral Vascular Access Device A. Blood specimen collection from a peripheral vascular access device is performed only at the time of initial insertion of the device. Do not routinely collect blood specimens from indwelling peripheral or midline catheters. B. Apply tourniquet. C. Select the appropriate vein for intended infusion therapy since catheter will be left in place post-blood collection (See policy for Peripheral Venous Access Placement). D. Attach blunt cannula of tube holder into catheter adapter of blood collection equipment, and advance specimen tube. Observe for backflow of blood into tube. Obtain desired amount of blood. Obtain blood specimens before initiating therapy. If more than one tube of blood is needed, change tubes slowly and steadily, taking care not to move catheter in cannulated vein and cause patient undue pain of discomfort. E. Release tourniquet.

12 F. Remove last tube from barrel holder and set aside. G. Stabilize VAD. H. Secure connection junctions. I. Dress access site. J. Initiate therapy. From Central Vascular Access Device (CVAD) A. Discontinue administration of all infusates into the CVAD prior to obtaining blood samples. B. Check patency of CVAD by flushing with 10ml preservativefree 0.9% sodium chloride (USP). C. When drawing from multi-lumen catheters, the distal lumen is the preferred lumen from which to obtain specimen (or the lumen recommended by the manufacturer). D. Blood samples may be collected from CVAD by syringe method or vacutainer, as recommended by the manufacturer of the CVAD. E. Specimens collected from certain CVADs may be adversely affected by catheter composition or material; check with CVAD manufacturer for recommendations on product use. Using the vacutainer method: A. Clamp catheter. B. Attach connector to vacutainer barrel holder. C. Place blood tube into vacutainer holder. D. Disinfect access cap with alcohol. E. Remove cover and insert vacutainer connector into access cap. F. Unclamp catheter. G. Advance blood tube inside vacutainer holder to activate retrograde blood flow. H. Hold tube in place until blood flow ceases: this is considered the discard.

13 I. The volume should be 1.5 to 2 times the full volume of the CVAD. J. Clamp catheter and remove blood tube from vacutainer holder, leaving holder connected to access cap. K. Discard blood tube immediately into appropriate container. L. Insert another blood tube, unclamp catheter, and obtain blood specimens as ordered. M. After all samples are collected, clamp catheter. N. Remove vacutainer holder and connector from access cap. O. Disinfect access cap with alcohol. P. Flush catheter using 10ml preservative-free 0.9% sodium chloride (USP). Q. Change access cap and extension set, if needed. Using the syringe method: A. Clamp catheter. B. Remove access cap and discard. C. Disinfect catheter hub with alcohol. D. Attach empty 5-ml syringe to catheter hub. E. Unclamp catheter. F. Withdraw 1.5 to 2 times fill volume of CVAD of blood and discard. G. Re-clamp catheter. H. Remove and discard syringe immediately into appropriate container. I. Attach second syringe to catheter hub, size to be determined by amount of blood needed. J. Unclamp catheter. K. Withdraw blood into syringe. L. Several syringes may be needed to obtain required amount of blood.

14 M. Re-clamp catheter and remove syringe. N. Cleanse catheter and remove syringe. O. Attach prefilled access cap attached to 10-ml syringe with 10ml preservative-free 0.9% sodium chloride (USP). P. Unclamp catheter. Q. Flush with preservative-free 0.9% sodium chloride (USP). R. Transfer blood to collection tubes or vials and rotate vials using appropriate needles or needleless system. S. If blood does not flow into the blood tube or syringe: Have patient change position, cough, move arm above head, or hold a deep breath. Attempt to flush catheter with preservative-free 0.9% sodium chloride (USP) and attempt to withdraw blood again. Replace blood tube with a new one. If still unsuccessful, notify physician. Draw the blood specimen peripherally. From Implanted Port A. Access implanted port B. Clamp extension set and remove access cap. C. Attach empty 10-cc syringe to hub of extension tubing and unclamp. D. Aspirate 3 to 5 cc of blood into syringe. E. Re-clamp extension set. F. Remove and discard syringe immediately into an appropriate container. G. Attach a syringe to extension tubing hub and unclamp. H. Withdraw blood into syringe. I. Several syringes may be needed to obtain required amount of blood.

15 J. Clamp extension tubing and remove syringe with blood. K. Transfer blood to collection tubes or vials and rotate vials using appropriate needles or needless system. L. Attach prefilled access cap attached to 10-ml syringe containing 10 ml preservative-free 0.9% sodium chloride (USP). M. Unclamp catheter. N. Flush with preservative-free 0.9% sodium chloride (USP). O. Clamp extension tubing and remove syringe. P. Attach heparin-filled syringe and unclamp catheter. Q. Flush with 3 to 5 ml heparin (100 units/ml), as appropriate. R. Remove noncoring needle Post-Blood Drawing If port is to remain accessed, see policy Implanted Port. A. Monitor patient s response. B. Label blood samples before leaving the patient s side with: Patient s name Patient ID number Date and time of specimen collection C. Send samples to testing laboratory: Place blood specimen in sealed container for transport. Identify container with BIOHAZARD label. Certain specimens may need to be placed on ice during transport; check with laboratory used by the organization. D. Discard used supplies in appropriate receptacles. E. Remove gloves. F. Wash hands. G. Document in patient s permanent medical record, including amount of blood used for sampling and patient response to

16 procedure. Catheter Removal A catheter shall be removed with an order from a physician or authorized prescriber when therapy is completed, during routine site rotation, when contamination or complication is suspected, or when tip location is no longer appropriate for prescribed therapy. Follow manufacturer s labeled use and directions for catheter removal. A nurse educated and competent in the removal of nontunneled, noncuffed CVADs may do so per organizational policy. Prior to Beginning Procedure A. Wash hands. B. Assemble equipment. C. Don sterile gloves and other PPE. D. Use aseptic technique and observe Standard Precautions throughout procedure. E. Educate patient as to procedure. F. Place patient in supine position for removal of all CVADs. Patient may assume sitting or reclining position for removal of peripheral-short or midline device. Catheter Removal Educate patient in Valsalva maneuver for all CVAD removal procedures. A. Discontinue administration of all infusates. B. Remove dressing from insertion site. C. Remove stabilization device. D. Inspect catheter-skin junction. E. Disinfect catheter-skin junction. F. Place first two fingers of nondominant hand lightly above catheter-skin junction site with gauze between fingers. G. Using gentle, even pressure, slowly retract catheter from site

17 with dominant hand while holding site with gauze. Use extreme caution when removing central nontunneled, noncuffed catheters or PICCs to prevent occurrence of air embolism. Patient to perform Valsalva maneuver during removal. H. If resistance or complication occurs, discontinue removal and notify physician immediately. I. Assess integrity of removed catheter. Compare length of catheter to original insertion length to ensure entire catheter is removed, and document in patient s chart. J. Dress exit site. Apply pressure to site with gauze for 30 seconds, minimum. Secure gauze to site, cover with occlusive material such a transparent semipermeable membrane (TSM) dressing. Change dressing every 24 hours until exit site is healed. K. For CVAD removal: Apply pressure to site with gauze for 30 seconds, minimum. Apply new gauze with application of approved antiseptic ointment to exit site. Secure gauze to site, cover with occlusive adhesive material. Change dressing every 24 hours until exit site is healed. Patient should remain in supine position for 30 minutes post-cvad removal. Post-Catheter Removal A. Discard used supplies. B. Remove gloves. C. Wash hands. D. If catheter defect is noted, report to manufacturer and regulatory agencies. Complete Occurrence Report as

18 established by the organization. E. Document in patient s permanent medical record. External Ref: Intravenous Nursing Society; Infusion Nursing an evidence based approach, 3rd edition, 2010 Policies and Procedures for Infusion Nursing 4th Edition, 2011 Internal Ref: Plumer s Principles and Practices of Intravenous Therapy; Weinstein,S., 1997 CDC Guideline for Access Devices 1996 Source: Clinical Managers, Compliance and Education Coordinators Approved by: FHI Assistant Director, Medical Director Date Effective: 03/19/1999, 1/1/2002 Date Revised: 10/2000, 4/04, 6/08, 2/10, 7/10, 8/2012, 12/2012 Date Reviewed: 8/2012, 12/2012

19 Revised on 8/2012 Code: D:PC-5100

20 Fairview Home Infusion (FHI) Infusion Access Device Guide last revised 11/2012 > 10kg to Adult Device/Catheter Routine Flush with Medication Administration Flushing with Blood Draws Flushing with No Therapy Dressing Change BioPatch Cap and/or Extension Set Change Clamping Vs. Non-Clamping Peripheral Venous Catheter (PIV) N/A* (Not used for blood draws) 0.9% Sodium Chloride 10 ml every 12 hours TSM*-with PIV restart; and prn Gauze-not recommended due to catheter dislodging and unable to visualize site With PIV restart Use clamp on extension set to prevent reflux of blood No BioPatch Midline, Openended (Extended Dwell Peripheral) - Heparin 10 units/ml 5 ml N/A (Not used for blood draws) Heparin 10 units/ml 5 ml every 24 hours TSM-weekly and prn Gauze-every 48 hours No BioPatch Cap weekly Ext set weekly Either anytime the device is compromised Use clamp to prevent reflux of blood Midline, Valved (Extended Dwell Peripheral) *exception for pregnant patients also use Heparin 10 units/ml 5ml N/A (Not used for blood draws) 0.9% Sodium Chloride 10 ml every 24 hours *exception for pregnant patients also use Heparin 10 units/ml 5ml TSM-weekly and prn Gauze-every 48 hours No BioPatch Cap weekly Ext set weekly Either anytime the device is compromised Clamping is unnecessary due to distal end of catheter design Clamp must always be available Do not use syringes smaller than 10ml to flush/ administer meds into catheter Heparin Allergy Anticoagulant Citrate may be used in equal volumes to heparin if patient is allergic TSM-Transparent Semi-permeable Membrane N/A-Not applicable

21 Fairview Home Infusion (FHI) Infusion Access Device Guide last revised 11/2012 > 10kg to Adult Device/Catheter Routine Flush with Medication Administration Flushing with Blood Draws Flushing with No Therapy Dressing Change BioPatch Cap and/or Extension Set Change Clamping Vs. Non-Clamping Central Lines, Openended (PICC, Nontunneled central catheter, tunneled chest catheter) - Heparin 10 units/ml 5 ml predraw - Draw 5ml blood discard prior to obtaining sample - 0.9% Sodium Chloride 20 ml postdraw - Heparin 10 units/ml 5 ml; then change cap Heparin 10 units/ml 5 ml every 24 hours TSM-weekly and prn Gauze-every 48 hours BioPatch with each dressing change Cap weekly & after each blood draw; Ext set weekly; Either anytime the device is compromised Use clamp to prevent reflux of blood Central Lines, Valved (PICC, Non-tunneled central catheter, tunneled chest catheter) predraw - Draw 5ml blood discard prior to obtaining sample - 0.9% Sodium Chloride 20 ml postdraw; then change cap 0.9% Sodium Chloride 10 ml every week *exception for pregnant patients also use Heparin 10 units/ml 5ml TSM-weekly and prn Gauze-every 48 hours BioPatch with each dressing change Cap weekly & after each blood draw; Ext set weekly; Either anytime the device is compromised Clamping is unnecessary due to distal end of catheter design *exception for pregnant patients also use Heparin 10 units/ml 5ml *exception for pregnant patients also use Heparin 10 units/ml 5ml Clamp must always be available Implanted Port, Open-ended predraw - Draw 5ml blood discard prior to obtaining sample - 0.9% Sodium Chloride 20 ml postdraw Heparin 100 units/ml 5 ml every month if not accessed Heparin 100units/ml 5ml daily if accessed but no therapy TSM-weekly with needle change Gauze-every 48 hours No BioPatch Cap weekly & after each blood draw; Ext set weekly; Either anytime the device is compromised Use clamp to prevent reflux of blood - Heparin 100 units/ml 5 ml - Heparin 100 units/ml 5 ml; then change cap Implanted Port, Valved predraw - Draw 5ml blood discard prior to obtaining sample - 0.9% Sodium Chloride 20 ml postdraw; then change cap 0.9% Sodium Chloride 10 ml every month if not accessed 0.9% Sodium Chloride 10ml daily if accessed but no therapy TSM-weekly with needle change Gauze-every 48 hours No BioPatch Cap weekly & after each blood draw; Ext set weekly; Either anytime the device is compromised Clamping is unnecessary due to distal end of catheter design *exception for pregnant patients also use Heparin 100 units/ml 5ml *exception for pregnant patients also use Heparin 100 units/ml 5ml *exception for pregnant patients also use Heparin 100units/ml 5ml Clamp must always be available Do not use syringes smaller than 10ml to flush/ administer meds into catheter Heparin Allergy Anticoagulant Citrate may be used in equal volumes to heparin if patient is allergic TSM-Transparent Semi-permeable Membrane N/A-Not applicable

22 Fairview Home Infusion (FHI) Infusion Access Device Guide last revised 11/ kg Device/Catheter Routine Flush with Medication Administration Flushing with Blood Draws Flushing with No Therapy Dressing Change BioPatch Cap and/or Extension Set Change Clamping Vs. Non-Clamping Peripheral Venous Catheter (PIV) - 0.9% Sodium Chloride 3 ml - 0.9% Sodium Chloride 3 ml N/A* (Not used for blood draws) 0.9% Sodium Chloride 3 ml every 8 hours TSM*-with PIV restart; and prn Gauze-not recommended due to catheter dislodging and unable to visualize site With PIV restart Use clamp on extension set to prevent reflux of blood No BioPatch Midline, Open-ended (Extended Dwell Peripheral) N/A (Not used for blood draws) Heparin 10 units/ml 3 ml every 24 hours TSM-weekly and prn Gauze-every 48 hours Cap weekly Ext set weekly - Heparin 10 units/ml 3 ml No BioPatch Either anytime the device is compromised Use clamp to prevent reflux of blood Midline, Valved (Extended Dwell Peripheral) N/A (Not used for blood draws) 0.9% Sodium Chloride 5 ml every 24 hours TSM-weekly and prn Gauze-every 48 hours Cap weekly Ext set weekly No BioPatch Either anytime the device is compromised Clamping is unnecessary due to distal end of catheter design Clamp must always be available Do not use syringes smaller than 10ml to flush/ administer meds into catheter Heparin Allergy Anticoagulant Citrate may be used in equal volumes to heparin if patient is allergic TSM-Transparent Semi-permeable Membrane N/A-Not applicable

23 Fairview Home Infusion (FHI) Infusion Access Device Guide last revised 11/ kg Device/Catheter Routine Flush with Medication Administration Flushing with Blood Draws Flushing with No Therapy Dressing Change Cap and/or Extension Set Change BioPatch Clamping Vs. Non-Clamping Central Lines, Openended (PICC, Nontunneled central catheter, tunneled chest catheter) - Heparin 10 units/ml 3 ml predraw - Draw 3ml blood discard prior to obtaining sample postdraw - Heparin 10 units/ml 3 ml; then change cap Heparin 10 units/ml 3 ml every 24 hours TSM-weekly and prn Gauze-every 48 hours BioPatch with each dressing change for patients > 37 weeks corrected age Cap weekly & after each blood draw; Ext set weekly; Either anytime the device is compromised Use clamp to prevent reflux of blood Central Lines, Valved (PICC, Non-tunneled central catheter, tunneled chest catheter) predraw - Draw 3ml blood discard prior to obtaining sample postdraw: then change cap 0.9% Sodium Chloride 5 ml every week TSM-weekly and prn Gauze-every 48 hours BioPatch with each dressing change for patients > 37 weeks corrected age Cap weekly & after each blood draw; Ext set weekly; Either anytime the device is compromised Clamping is unnecessary due to distal end of catheter design Clamp must always be available Implanted Port, Open-ended predraw - Draw 3ml blood discard prior to obtaining sample postdraw Heparin 100 units/ml 3 ml every month if not accessed Heparin 100units/ml 3ml daily if accessed but no therapy TSM-weekly with needle change Gauze-every 48 hours No BioPatch Cap weekly & after each blood draw; Ext set weekly; Either anytime the device is compromised Use clamp to prevent reflux of blood - Heparin 100 units/ml 3 ml - Heparin 100 units/ml 3 ml: then change cap Implanted Port, Valved predraw - Draw 3ml blood discard prior to obtaining sample postdraw; then change cap 0.9% Sodium Chloride 5 ml every month if not accessed 0.9% Sodium Chloride 5ml daily if accessed but no therapy TSM-weekly with needle change Gauze-every 48 hours No BioPatch Cap weekly & after each blood draw; Ext set weekly; Either anytime the device is compromised Clamping is unnecessary due to distal end of catheter design Clamp must always be available Do not use syringes smaller than 10ml to flush/ administer meds into catheter Heparin Allergy Anticoagulant Citrate may be used in equal volumes to heparin if patient is allergic TSM-Transparent Semi-permeable Membrane N/A-Not applicable