Community Nurse Referral Letter (PICC Care)

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1 Community Nurse Referral Letter (PICC Care) Name of nurse making the referral: Name Signature.. Date Ward.Tel Ext. Dear Community Nurse The following patient requires care for a PICC (Peripherally Inserted Central Catheter): Name.....DOB..... Diagnosis... Address... Tel... GP Please visit as follows.. The PICC has been checked by X-Ray. If the line is pulled out by more than 5cm please inform us. As a baseline please note that on discharge the measurement between hub and exit site was as follows: Page 1 of 7 continues overleaf UCL Hospitals is an NHS Foundation Trust incorporating the Eastman Dental Hospital, Elizabeth Garrett Anderson & Obstetric Hospital, The Heart Hospital, Hospital for Tropical Diseases, National Hospital for Neurology & Neurosurgery, The Royal London Homoeopathic Hospital and University College Hospital.

2 continued. Please note We have recently stopped using hepsal for locking lines We have recently changed our exit site cleaning regime. We are now using Chloraprep Dressing change & flush are due weekly: instructions attached Blood tests: if required patient will be given blood forms with dates for when the tests are due. Please take blood from the PICC and sent to your usual Path lab. Instructions attached. Print off your own copies of the attached information from our website at A Note About Infection: Most patients on chemotherapy are immunocompromised and infections should be acted on immediately. If the patient experiences a rigor and/or pyrexia following flushing of the line, contact the hospital urgently. Haematology pts: contact Bleep Oncology Pts: contact If the exit site is inflamed or there is purulent exudate, please take a swab. If the patient is pyrexial, contact the hospital urgently as above. If not, this can wait until the next working day. The site should be inspected daily while infection is suspected and use of Biopatch & Chloraprep should be suspended until the infection has resolved. Handwashing and a non-touch technique are vital: please follow attached instructions. Tick PICC discharge checklist to be completed by nurse referring patient Patient supplied with items in List A (see below). Subsequently supplied by community team. Patient supplied with enough items in List B (see below). Patient / carer knows to collect items from List B each time they attend the hospital Copy of this referral to be faxed to you Hard copy of this referral to be given to patient Patient knows who to contact if they have a problem with their PICC Signed..Date List A Dressing pack x 2 Transparent dressings x 2 Steristrips x 2 10 ml syringes x 10 Green needles x 10 Clinell wipes x 10 1 box 0.9% saline 10mls (IV use) Sharps bin List B Chloraprep Sepp.67mls Statlock dressings Biopatch Bionectors Large yellow bags x 2 for disposal of chemo (if required) Page 2 of 7 continues overleaf For advice or to arrange teaching contact Central Venous Access Team Tel: ext

3 Flushing a PICC Community nurse referral for PICC Care page 3 / 7 Our PICCs are fitted with Bionectors rather than bungs. These are needle-free access ports. YOU SHOULD NEVER STICK NEEDLES INTO them, and they need to be changed once a week. Please treat each lumen separately, using a different syringe for each lumen. Most of our PICCs do not have clamps because each lumen has a valve which keeps air from entering when the Bionector is changed. Routine Flushing: weekly for unused lumens. 1. Wash hands. Draw up saline into syringes. 2. Clean end of Bionector with 2% chlorhexidine swab. Rub vigorously for 30 seconds using different parts of the swab. 3. Allow to dry fully without becoming contaminated (OR if Bionector change is due, remove Bionector, clean end of lumen with alcohol swab, allow to dry, apply new Bionector and proceed.) 4. Remove needle from saline syringe. Push the syringe into the Bionector and twist clockwise. The syringe should now stay in place. Equipment Needed per lumen 10 mls 0.9% Saline IV 10 ml syringe (no smaller) Needle 2% Chlorhexidine in alcohol swabs Sterile towel Spare Bionector if change due 5. Flush the PICC using a brisk push-pause technique (ie pause after each ml: this creates turbulence in the line and helps clear any tiny debris). DO NOT FORCE THE FLUSH or you may split the PICC. If you meet resistance, STOP and contact the hospital for advice. Never use a smaller syringe to try to unblock the PICC. 6. Remove syringe by twisting anti-clockwise while flushing in the last ml of saline. Leave Bionector in place. Taking blood from a PICC. Equipment Needed As for routine flush (above) but add: two extra empty 10 ml syringes (or one extra syringe plus Vacutainer connector) 2 x 10ml syringes of saline and a spare in case PICC needs flushing before it will bleed back. 1. Access the PICC using aseptic technique as for flushing. 2. Withdraw & discard first 4mls of blood from PICC. (If it won t bleed back try flushing the line first or ask patient to take deep breaths.) 3. Take the blood sample. 4. Flush immediately with 2 x 10mls 0.9% saline: turbulent push-pause flush. Further info: Print off your own copy at Contact Nurse Specialists: Tel: x Out of hours: Haematology patients contact Bleep Oncology patients contact Updated by Liz Simcock October 2009 If you are flushing off chemotherapy Chemotherapy can damage cells. Avoiding contact with chemotherapy is like avoiding radiation in an X-ray department. Repeated exposure can be harmful. This is why it must be handled with care. Always wear apron and gloves when handling lines, bags and infusion devices containing Chemotherapy Disconnect the giving set from the PICC leaving the Bionector in place. Avoid dripping or splashing of the Chemotherapy. Dispose of contaminated equipment carefully in a double yellow bag including the empty infusion device, the syringe used to flush the line through and your gloves and apron The yellow bag can be brought back to the hospital by the patient at his / her next visit for disposal by the chemotherapy nurses. In the meantime it should always be stored out of the reach of children. Always wash your hands on removing your gloves and apron. In the event of a spillage Chemotherapy can cause irritation if it comes into direct contact with the skin. If for any reason this should happen, flush the affected area with plenty of water and a mild soap. If any burning or rash develops subsequently, seek medical advice.

4 Chloraprep and Biopatch Community nurse referral for PICC Care page 4 / 7 Chloraprep Sepp.67mls is a single-use sterile applicator containing a 2% solution of Chlorhexidine Gluconate and 70% Isopropyl Alcohol. It s coverage area is 5cm x 8cm. It works by penetrating the top 5 layers of the skin where most bacteria is found. At UCLH Cancer Services and Adolescent Cancer we are now using Chloraprep for cleaning all our Central Venous Catheter exit sites including PICCs. Can it be used for all patients? Patients must be aged 2 months and over. Adverse reactions are very rare but can cause anaphylaxis. Do not use on patients with a history of hypersensitivity to Chlorhexidine. How should it be used? Pinch the sides of the applicator once (in the middle of the ampoule) until you feel the inner ampoule break. The antiseptic solution will soak the sponge tip. Use a gentle repeated back-and-forth friction rub for 30 seconds and allow to dry completely. Discard in clinical waste bag. If there is loose blood or exudate around the exit site, clean this away using 0.9% saline before using Chloraprep. Biopatch is a disc-shaped foam dressing impregnated with Chlorhexidine Gluconate. Biopatch inhibits bacterial growth. At UCLH we are now using it on all our Central Venous Catheter exit sites including PICCs (except for patients under the age of 16). Can it be used for all patients? Patients must be aged 16 or over. Adverse reactions are very rare but can cause anaphylaxis. Do not use on patients with a history of hypersensitivity to Chlorhexidine. How is Biopatch applied? The Biopatch should be placed around the PICC exit site with the BLUE side up The catheter should rest on top of the Biopatch near the radial slit. A IV-dedicated transparent dressing should then be applied. For patients unable to tolerate a transparent dressing try a dry dressing (eg Mepore). How often should it be changed? Change the Biopatch and the dressing every 7 days or sooner if the dressing becomes detached the Biopatch is more than half discoloured with blood / exudates the white edges of the Biopatch become visible around edges of blue disc What if the exit site looks infected? If the exit site is visibly infected: STOP using Biopatch & Chloraprep. Take a swab and contact the GP or hospital. Change dressing daily and clean with 0.9% saline until the infection is resolved. Do Chloraprep & Biopatch need prescribing & can they be obtained in the Community? They do NOT need to be prescribed. They can be hard to obtain in the Community. Patients should be sent home with a supply and should collect a few more each time they visit the hospital. Further information: Print off your own copy of attached info at Contact Nurse Specialists: Tel: x Out of hours: Haematology patients contact Bleep Oncology patients contact Updated by Liz Simcock October 2009

5 Changing a PICC Dressing Community nurse referral for PICC Care page 5 / 7 Clean hands & put on non-sterile gloves Remove dressing DO NOT pull on PICC! Remove steristrip DO NOT pull on PICC! Gently remove Biopatch Remove Statlock DO NOT pull on PICC! Prise off transparent wings & remove Statlock Squeeze Chloraprep Sepp to soak sponge 30 seconds friction rub back & forth (covers 5 x 8 cm) Allow to dry Attach new Statlock dressing DON T pull on PICC! Prepare skin using skinprep pad (in Statlock pack) Apply Statlock Curve PICC away from elbow joint Clean hands again Put on sterile gloves Apply Biopatch Apply Steristrip Apply transparent dressing Further information: Print off your own copy of attached info at Contact Nurse Specialists: Tel: x Out of hours: Haematology patients contact Bleep Oncology patients contact Updated by Liz Simcock October 2009

6 PICC Troubleshooting Community nurse referral for PICC Care page 6 / 7 Patient is pyrexial (above 38 o C) and / or experiences a rigor: Contact the hospital urgently for advice. May need IV antibiotics. Exit site looks infected (inflammation / exudate around exit site) If the patient is pyrexial see above. Take a swab. Contact the hospital or GP. May need oral antibiotics. Stop using Biopatch until infection resolved. Daily dressing changes if exudate is present & clean with 0.9% saline. Sore, swollen inflamed arm above the PICC insertion site Contact the hospital. This might be a thrombosis. PICC is blocked: Contact the Central Venous Access Team (see contact details below). PICC will not bleed back: If you are just doing a routine flush don t worry. If you need to administer iv medications or take blood samples contact the Central Venous Access Team. PICC has been pulled out by more than 5cm: Must be x-rayed before continuing with treatment. Contact the hospital. PICC has been cut, split or damaged: Fold the line over on itself between the break and the patient and secure with tape. This will prevent air entry. Contact the hospital. PICC may need to be removed (see below) but note that PICCs can sometimes be repaired. If the PICC needs to be removed 1. Check your manager is happy for you to remove PICC 2. Place PICC exit site below the level of the heart. 3. Remove the dressing. 4. Pull PICC out slowly an inch or two at a time. 5. If you meet resistance, STOP. Do not risk snapping the line. 6. Resistance may be due to venospasm. Wait 5 minutes before resuming. Applying warm packs to the patient s arm may help. If not, contact the hospital. 7. Once the PICC is out, apply pressure to the exit site with sterile gauze. 8. Apply air-proof dressing. Equipment Non-sterile gloves Gauze swabs Air-proof dressing Further information: Print off your own copy of attached info at Contact Nurse Specialists: Tel: x Out of hours: Haematology patients contact Bleep Oncology patients contact Updated by Liz Simcock October 2009

7 Central Venous Catheter Care Training for Community Nurses Ever wished you knew more about Hickmans, Portacaths or PICCs? One-off teaching sessions for Community Nurses. Cost: 20 This is not a substitute for IV training but we do cover: What is a Central Venous Catheter? Hickmans, PICCs and Portacaths Flushing and Dressing techniques Recognising and Preventing Complications DATES FOR th Jan / 22 nd March / 17 th May 12 th July / 6 th Sept / 31st Dec All sessions Obtain application form by: phone: ext 77491

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