Care and Removal of Peripherally Inserted Central Catheters (PICC) for Adults

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1 Approved by: Care and Removal of Peripherally Inserted Central Vice President and Chief Medical Officer; and Vice President and Chief Operating Officer Corporate Policy & Procedures Manual Number: Date Approved July 7, 2014 Next Review (3 years from Effective Date) July 2017 Purpose To identify standards of care for patients with peripherally inserted central catheters (PICC). To act as a resource for staff so that errors leading to complications are reduced. To identify and comply with current best practices from infection control and infusion nursing standards. To ensure that health care professionals who care for, maintain and remove PICCs have education and demonstrated competency. Policy Statement Only those health care professionals who have completed the required educational program and have demonstrated competency will care for and/or remove Peripherally Inserted Central catheters. All PICC shall be reviewed daily for line necessity. Unnecessary lines will be removed promptly. Applicability This policy and procedure applies to all Covenant Health facilities, staff, physicians, volunteers, students and any other persons acting on behalf of Covenant Health. Responsibility Health care professionals who care for, maintain or remove PICCs must clearly understand their indications for use and the potential for complications and adhere to current evidence-based practices outlined herein. Health care professionals shall demonstrate compliance with this policy and procedure by: adhering to the education requirements ensuring that they understand the appropriate care and maintenance needed to prevent infection/complication after the PICC is inserted provide proper care of the PICC post-insertion to preventing Central Line Associated Blood Stream Infections (CLABSIs). Principles Knowledgeable and educated health care professionals reduce the risk of central line associated blood stream infections and other complications Using infection prevention maintenance bundles decreases central line associated blood stream infections. Indications for use of central venous catheters: Administration of medications, such as chemotherapy or antibiotics Administration of fluids, including blood components or blood products Monitoring of central venous pressure Providing parenteral nutrition

2 2 of 21 Advantages of PICCs are: reliable long term access (therapy from six days to one year) eliminates risk of pneumothorax suitable for vesicants and hyperosmolar solutions easily managed on an outpatient basis Disadvantages of PICCs higher incidence of DVT small lumen size therefore not appropriate for high volume infusions/resuscitation Requirements: Education / Demonstrated Skills Definitions See Demonstration Skills Checklists Performance Criteria StatLock PICC Dressing Performance Criteria SecurAcath PICC Dressing Performance Criteria Every 96 hours Injection Cap change PICC Removal Demonstration Checklist For the purpose of this policy and procedure: Scrub the hub means: Each time the injection cap is entered it must be cleaned with an alcohol or chlorhexidine/alcohol wipe. Scrub the injection cap with the wipe for 15 seconds using friction and allow the solution to dry. Catheter flush is a technique whereby the solution is pushed through the catheter into the bloodstream (no dwell time) Catheter lock is a technique by which a solution is injected into the catheter lumen dead space until it is filled and then allowed to dwell for a period of time, until the catheter is accessed again. Health care professional means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act or the Health Professions Act, and who practices within scope or role. Related Documents Appendix A - PICC Dressing Change Principles Attached Demonstration Skills Checklists: Performance Criteria StatLock PICC Dressing Performance Criteria SecurAcath PICC Dressing Performance Criteria Every 96 hours Injection Cap change PICC Removal Demonstration Checklist Insertion of Peripherally Inserted Central Catheters (PICC)Policy (in development) References Alexander, M. (Jan/Feb 2011) Infusion nursing standards of practice. Journal of Infusion Nursing, supplement, Vol. 34, #1S, S110. Alexander, M., Corrigan, A., Gorski, L., Hankins, J., Perucca, R. Infusion Nurses Society: Infusion

3 3 of 21 Previous Version (date) Nursing: An evidence-based Approach. 3 rd Edition Centres for Disease Control and Prevention. (2011). Guidelines for the prevention of intravascular catheter-related infections, Self-published. Doellman, D. et al (2009). Infiltration and Extravasation: Update on prevention and management. Journal of Infusion Nursing. Vol. 32, No. 4. Hadaway, L.(2007) Emergency: Infiltration and Extravasation: Preventing a complication of IV catheterization. American Journal of Nursing. Vol. 107, No. 8. Infectious Diseases Society of America. (April 1, 2011) Guidelines for the Prevention of intravascular catheter-related infections. Oxford University Press. CID 2011:52 (1 May). Infusion Nurses Society. Policies and procedures for infusion nursing. 4 th edition Registered Nurses Association of Ontario. (2004). Nursing Best Practice Guideline: Assessment and Device Selection for Vascular Access Registered Nurses Association of Ontario. (2005). Nursing Best Practice Guideline: Care and Maintenance to reduce vascular access Complications The Canadian Patient Safety Institute. Getting started kit; prevent central line infections. Central line associated blood stream infections. Safer healthcare now! Campaign. February The Joint Commission, J Preventing central line-associated bloodstream infections: a global challenge, al global perspective. Oak Brook IL: Joint commission resources, May CLABSIs.pdf. International evidence-based recommendations on ultrasound-guided vascular access. Intensive care medicine, Published online 22 May Thibodeau S. Riley J, Rouse K. Effectiveness of new flushing and maintenance policy using peripherally inserted central catheters for adults. Best practice. Journal of Infusion Nursing. 2007;30(5): Hadaway L. Heparin locking for central venous catheters. Journal of Association for Vascular Access. 2006; 11 (4): Hadaway L. Misuses of prefilled flush syringes. Infection Control Resources. 2008;4(4):2-4 Casey AL, Elliot TS. Infection risks associated with needleless intravenous access devices. Nurs Stand. Nov ; 22(11): Field K, McFarlene C, Cheng A,et al. Incidence of catheter related bloodstream infection among patients with a needleless, mechanical valve-based intravenous connector in an Australian hematology-oncology unit. Infect Control Hosp Epidemiol. 2007;28(5): Maragakis L. Bradley K, Song X, et al. Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port. Infect Control Hosp Epidemiol. 2006;27(12): Muslimani A, Ricaurte B, Daw H. Immune heparin-induced thrombocytopenia resulting from preceding exposure to heparin catheter flushes. American Journal of Hematology. Dec 18, 2006 epub 2006 N/A

4 4 of 21 PAGE(S) 1.0 INFECTION PREVENTION & CONTROL PATIENT SAFETY ENSURING PATENCY & FLUSHING PICC GUIDELINES FOR LOCKING PICC Open-Ended PICCs 4.2 Close-Ended / Valved PICCs 5.0 INJECTION CAP CHANGE PICC DRESSING CHANGE USING STATLOCK SECUREMENT PICC DRESSING CHANGE USING SECURACATH PATIENT ASSESSMENT PATIENT TEACHING For Inpatients 9.2 For Outpatients 10.0 DOCUMENTATION REMOVAL OF PICC DOCUMENTATION OF REMOVAL COMPLICATIONS Appendix A - PICC Dressing Change Principles. 21

5 5 of INFECTION PREVENTION & CONTROL 1.1 To minimize the risk of Central Line Associated Blood Stream Infection (CLABSI) associated with direct contact of the hands of health care personnel, hand hygiene is to be performed at the following times; before and after palpating the site of catheter insertion before and after inserting the catheter before and after accessing, replacing, repairing, or dressing the catheter Aseptic technique is required for all instances of PICC care. Aseptic technique is also referred to as sterile technique and is used to keep objects and areas free of microorganisms and thereby minimize infection risk for the patient. 1.2 Strict aseptic technique is required for: 1. administration set changes, 2. dressing changes, 3. injection cap changes. 1.3 Hands are to be cleansed with alcohol based hand sanitizer and clean gloves worn prior to flushing, locking, handling administration sets, etc. 1.4 Sterile gloves and mask must be worn for dressing changes. 1.5 To maintain a closed system attach an injection cap (eg. split septum) to lumen ends. Attach administration sets to the injection cap. 1.6 The external surface of a catheter hub, connector, or injection port is the immediate portal of entry of microorganisms to the intraluminal surface of the catheter. Microorganisms entering the system attach at any point of contact along the intraluminal surface. The colonizing organisms form within the needleless connector, catheter hub, and lumen and can be dispersed into the bloodstream, resulting in CLABSI. It is critical, therefore, that these surfaces be thoroughly disinfected with chlorhexidine/alcohol wipe before they are accessed. Scrub the hub for 15 seconds and allow solution to dry completely. Scrub the hub: Each time the injection cap is entered it must be cleaned with an alcohol or chlorhexidine/alcohol wipe. Scrub the injection cap with the wipe for 15 seconds using friction and allow the solution to dry. 2.0 PATIENT SAFETY 2.1 Proper maintenance of PICC is essential for continued patient safety. 2.2 Daily assessment of line necessity: Risk of CLABSI increases with the duration of time the catheter is left in place, so evaluation of the continued need for a catheter is an important aspect of CLABSI prevention; Catheters that are no longer needed should be promptly removed.

6 6 of Daily review of the continued need for CVCs can be done during multidisciplinary patient care rounds or by using reminders, such as stickers on patient records or order sets, or via automated computer alerts. 2.3 Infuse all solutions, blood products, and medications via administration sets with luer lock connections. NOTE: Do not take blood samples or insert a peripheral intravenous catheter in arm with PICC. If no other site is available for blood specimen collection, the hand on the PICC side may be used Do not take blood pressure from arm with PICC as this can cause compression of catheter which could lead to occlusion or severing of catheter. Post sign at patient s bedside to alert all hospital staff. 3.0 ENSURING PATENCY & FLUSHING PICC NURSING ALERT: All administration sets, extension tubing, or intermittent injection caps attached to central lines must have luer lock connections. Always use a 10 cc syringe or large barrel syringe for flushing as it has a lower pressure rating. Smaller syringes have greater pressures and may rupture catheter. Once patency has been confirmed small quantities of medication in syringes of appropriate size for the dose may be administered. 3.1 Scrub the hub. Ensure catheter patency by using a syringe to withdraw and observe for blood return, then flush to clear the catheter of blood. The catheter should flush without resistance or leaking from insertion site. Flush with preservative free saline for injection to clear the line of medications prior to locking. When flushing and/or locking, use Positive Pulsing Pressure by giving short jerky pushes on plunger. 3.2 If unable to obtain blood return, or there is resistance to flushing, the nurse should take further steps to assess patency (eg. is the clamp off?) If withdrawal occlusion observed, report it as soon as possible because this is the optimal time to manage occlusions. All complete occlusions should be managed or the catheter removed and replaced if still necessary. Refer to Corporate Policy #VII-B-335, Occlusion Management of Central Venous Catheters). 3.3 Patency is confirmed at the following times: Continuous infusions: with injection cap / administration set changes and prn Intermittent infusions: prior to administration of flush solution / medication PICCs not in use: with daily locking solution administration.

7 7 of 21 NURSING ALERT: If IV solution does not readily infuse or lumen cannot be locked without meeting resistance, DO NOT apply force in attempt to free catheter of clot that may have formed. Occluded catheters increase the risk of catheter related blood stream infections. Notify physician and/or NP or designee to consider restoring patency to occluded lumen or to replace catheter. 3.4 Frequency of flushing: 20 ml saline flush After blood sampling. Before and after blood component administration 10 ml saline flush When converting from continuous to intermittent therapies Before and after intermittent medication therapy For maintenance of dormant PICCs. 4.0 GUIDELINES FOR LOCKING PICC 4.1 Open-ended PICCs Maintain the patency of each unused lumen by locking the catheter. Locking solutions in order of preference are: 1. 3 ml Sodium citrate 4% in a 10 ml syringe 2. 5 ml of heparin lock solution (10 units/ml) or, if not available, 3. 3 ml heparin lock solution (100 units/ml) q24 or as ordered The volume should be at least twice the volume capacity of the catheter lumen plus the priming volume of all add-on devices (eg. extension tubing) To maintain the patency of catheters locked between medications follow SASS or SASH: o Saline to assess catheter patency o Administration of medication o Saline to flush medication out of catheter o Sodium citrate or Heparin Lock to maintain patency between medication. Heparin locking: Platelet count monitoring is recommended for post-op patients every 2-3 days from day 4-14, or until therapy with heparin is stopped. A decrease in platelet count may indicate Heparin Induced Thrombocytopenia If the PICC has a clamp, clamp before removing blunt cannula/syringe from injection cap. Clamp the catheter when not in use with the clamp provided. Vary position of clamp along lumen to prevent wearing of catheter lumen. If catheter has a clamp, it must be clamped when not in use. If clamp has fallen off, if possible obtain replacement clamp and attach to CVC extension.

8 8 of Closed ended / valved PICC (Groshong / Solo / Neutral displacement connector) Maintain the patency of each lumen by locking with 10 ml of normal saline for injection qweek or as ordered. Guidelines for locking: If using interlink system: Since the PICC doesn t have a clamp, apply positive pressure by withdrawing the blunt cannula while injecting the last 0.5 ml of normal saline. The volume should be at least twice the volume capacity of the catheter lumen plus the priming volume of all add-on devices (eg. Injection cap, extension tubing). 4.3 Change equipment as outlined in Corporate policy #VII-B-330, Maintenance of IV/Hypodermoclysis Equipment. 4.4 Indicate equipment and dressing changes in Kardex. 5.0 INJECTION CAP CHANGE 5.1 If catheter is open ended, air embolism is avoided by positioning the insertion site below the level of the heart and clamping catheter prior to changing injection caps and/or extension sets. If the clamp has fallen off, have the patient exhale while changing the cap. Replace clamp if possible. 5.2 Cleanse the connection between the catheter hub and injection cap with antiseptic swab for 15 seconds. Using no touch technique, remove the old injection cap and replace with a new sterile injection cap taking care not to touch the threads of the catheter hub or to contaminate the threads of the new sterile cap. Some injection caps require priming prior to attaching to PICC, therefore follow cap manufacturer s directions. If threads of catheter hub are dirty, prior to attaching new injection cap, cleanse hub threads with chlorhexidine alcohol wipe being careful that cleansing solution does not enter catheter. 6.0 PICC DRESSING CHANGE USING STATLOCK SECUREMENT Equipment Sterile dressing tray Clean gloves Sterile gloves Chlorhexidine 2% /alcohol 70% swab sticks 3 to 4 or more as appropriate Sterile skin barrier film (eg. Cavilon TM No Sting Barrier Film) Transparent Dressing use as many as required to ensure a minimum of 1 inch (or 2.5 cm) around insertion site and to cover the entire external portion of catheter, StatLock and catheter suture wing. Dressing choice may be a transparent film dressing or transparent film which contains chlorhexidine/ antiseptic components as appropriate for your area and the brand of PICC you are covering. Try to minimize the amount one dressing overlaps another dressing. StatLock. Mask

9 9 of 21 This is a PICC suture wing This is a PICC extension hub 6.1 Perform hand hygiene. Assemble equipment. Don mask. Don clean gloves and use hospital disinfectant to clean over-bed table or procedure table prior to opening sterile supplies. Remove gloves. Perform hand hygiene. 6.2 Open sterile dressing tray and aseptically add dressing supplies to the dressing tray, being careful to keep all supplies sterile. Note that the chlorhexidine swab sticks and barrier film swab stick packages may be opened and arranged at the edge of the sterile field when clean gloves are used for cleansing or sterile forceps may be used to transfer stick to sterile tray so they may be easily retrieved with sterile gloves. 6.3 Don clean gloves. Gently and carefully remove transparent film dressing by supporting the skin and the catheter with your fingers and either stretching the dressing laterally to break the adhesive, or gently peeling back the dressing by folding the dressing back over itself. Do not pull the dressing up from the skin because this may cause epidermal or skin stripping. Remove dressing from the suture wing towards the insertion site. To aid in lifting a dressing edge, a piece of tape may be used in a corner. NOTE: Use caution to ensure that PICC is not accidentally pulled out during dressing change when StatLock is being replaced. Anchor the catheter securely to avoid dislodgement when PICC not secured by securement device. Hold the suture wing with clean gloves at the time of StatLock removal and before cleansing skin and external catheter. IF THE PICC BECOMES DISLODGED, NEVER PUSH PICC BACK INTO VEIN. 6.4 Using a chlorhexidine/alcohol swabstick, remove the StatLock from the skin by gently inserting the swab tip under it and moving the swab tip back and forth in a see-saw motion to dissolve the adhesive. Continue until the StatLock is completely removed from the skin. Do not pull it off the skin with force.

10 10 of 21 Note: Either clean or sterile gloves may be worn when cleaning skin and external catheter. Hand hygiene must occur prior to donning sterile gloves. 6.5 Using chlorhexidine / alcohol swabstick and using friction, cleanse skin around the insertion site and skin that will be under the dressing in a back and forth, then up and down motion. An application time of 30 seconds is required to kill bacteria on and within the layers of the skin. Using new swabstick, cleanse along external catheter from insertion site up to and including suture wing. Repeat using the other side of the swabstick, cleansing the underside of the external catheter and suture wing. Ensure that clean gloves to not touch newly cleaned skin or external catheter. 6.6 Let cleanser air dry completely. Drying time is usually two minutes, but may be much longer on humid days or if preparations that do not contain alcohol are used. 6.7 Apply sterile skin barrier film (eg. Cavilon TM No Sting Barrier Film) onto the skin, avoiding a 1 cm area around the insertion site. Except for the area immediately around the insertion site, all skin that will be covered by the dressing should be painted with the skin barrier film. Ensure that the barrier film is completely dry before applying the dressing. Exception: If using Tegaderm CHG IV Securement Dressing or Biopatch, do not use a barrier film to the area of antimicrobial delivery in order to allow penetration of the chlorhexidine product. The chlorhexidine impregnated area should cover the insertion site. 6.8 Sterile gloves required. If wearing clean gloves, remove them, perform hand hygiene and don sterile gloves. Place PICC suture wing into the new StatLock, grasping PICC suture wing and place suture holes over posts of StatLock device one side at a time and close lids one at a time, while stabilizing the catheter and keeping finger under pad so that no pressure is applied to your patient. 6.9 Without removing adhesive backing, position StatLock device on the arm so that PICC will not kink with arm movement. Peel away the adhesive backing from the StatLock one side at a time, adhere the device to the skin.

11 11 of Ensure arm is fully extended; apply transparent film dressing, being careful not to stretch the dressing. Gently lay the film at the desired location, and using firm pressure, press the film down onto the skin, working from the insertion site (middle of the dressing) toward the outside border. Not stretching the transparent film prevents skin stripping and tension blisters on the skin. Use as many transparent dressings as required to cover 2.5 cm around the insertion site, the entire external catheter, the StatLock device, and the catheter suture wing. Minimize the overlap of dressings Label dressing with PICC, your initials and the date the dressing was changed. 7.0 PICC DRESSING CHANGE USING SECURACATH SECUREMENT Equipment Sterile dressing tray Clean gloves Sterile gloves Chlorhexidine 2% /alcohol 70% swabstick 3 to 4 or more as appropriate Sterile skin barrier film (e.g. Cavilon TM No Sting Barrier Film) Transparent Dressing use as many as required to ensure a minimum of 1 inch (or 2.5 cm) around insertion site and to cover the entire external portion of catheter, SecurAcath and catheter suture wing. Dressing choice may be a transparent film dressing or transparent film which contains chlorhexidine/antiseptic components as appropriate for your area and the central venous catheter you are covering. Try to minimize the amount one dressing overlaps another dressing. Mask 7.1 Perform hand hygiene. Assemble equipment. Don mask. Don clean gloves and use hospital disinfectant to clean over-bed table or procedure table prior to opening sterile supplies. Remove gloves. Perform hand hygiene. 7.2 Open sterile dressing tray and aseptically add dressing supplies to the dressing tray, being careful to keep all supplies sterile. Note that the chlorhexidine swabstick and barrier film swabstick packages may be opened and arranged at the edge of the sterile field when clean

12 12 of 21 gloves are used for cleansing or sterile forceps may be used to transfer stick to sterile tray so they may be easily retrieved with sterile gloves. 7.3 Don clean gloves. Gently and carefully remove transparent film dressing by supporting the skin and the catheter with your fingers and either stretching the dressing laterally to break the adhesive, or gently peeling back the dressing by folding the dressing back over itself. Do not pull the dressing up from the skin because this may cause epidermal or skin stripping. Remove dressing from the hub towards the insertion site. To aid in lifting a dressing edge, a piece of tape may be used in a corner. Remove gloves. Note: Either clean or sterile gloves may be worn when cleaning skin and external catheter. Hand hygiene must occur prior to donning sterile gloves. 7.4 If blood is present on SecurAcath device, use saline soaked gauze or dry gauze to remove the blood. If touching unsterile extension use sterile dry gauze to protect sterile gloves. Gently lift the catheter and SecurAcath device, using chlorhexidine/alcohol swabstick, and using friction, clean around the catheter insertion site. Cleanse the insertion site and skin that will be under the dressing in a back and forth motion. Repeat using the other side of the swabstick then cleanse in an up and down motion. An application time of 30 second is required to kill bacteria on and within the layers of the skin. 7.5 Using new chlorhexidine/alcohol swabstick, cleanse along external catheter from insertion site, soak the SecurAcath device, and then cleanse up to and including the suture wing. Repeat using the other side of the swabstick, cleansing the underside of the external catheter, SecurAcath and suture wing. Let cleanser air dry completely. Drying time is usually two minutes, but may be much longer on humid days or if preparations that do not contain alcohol are used. 7.6 Apply sterile skin barrier film (e.g. Cavilon TM No Sting Barrier Film) onto the skin, avoiding a 1 cm area around the insertion site. Except for the area immediately around the insertion site, all skin that will be covered by the dressing should be painted with the skin barrier film. Ensure that the barrier film is completely dry before applying the dressing. Exception: If using a Tegaderm CHG IV Securement Dressing or Biopatch, do not use a barrier film to the area of antimicrobial delivery in order to allow penetration of the chlorhexidine product. The chlorhexidine impregnated area should cover the insertion site and sutures if any. 7.7 Ensure that the SecurAcath device is not twisted or rotated because this causes pain. SecurAcath will automatically fall into a comfortable neutral position.

13 13 of Fully extend arm and apply transparent film dressing, being careful not to stretch the dressing. Gently lay the film at the desired location, and using firm pressure, press the film down onto the skin, working from the insertion site (middle of the dressing) toward the outside border. Not stretching the transparent film prevents skin stripping and tension blisters on the skin. Use as many transparent dressings as required to cover 2.5 cm around the insertion site, the entire external catheter, the SecurAcath device, and the catheter suture wing. Minimize the overlap of dressings. 7.9 Label dressing with PICC, your initials and the date the dressing was changed. 8.0 PATIENT ASSESSMENT 8.1 Assessment requires observation for systemic complications as well as observation and palpation of insertion site moving proximal up the catheter route. Observe the catheter and insertion site for: Edema / swelling of hand, arm or dilated chest vessels Redness at site or colour differences between limbs Tenderness along PICC course Drainage at site Dislodgement / malposition or advancement of catheter Unusual pain or sensations (neck pain, hearing the infusion) Systemic signs or symptoms (see complications) 8.2 Report any of the above to the physician, NP or designee. 8.3 Site should be assessed every shift, pre-infusion, during infusion and immediately post-infusion. NURSING ALERT: Patients who have had a PICC line for a length of time may develop a small amount of scarring around the catheter exit site. The skin will become slightly reddened and raised without being irritated or swollen.

14 14 of PATIENT TEACHING 9.1 For inpatients: Reinforce to patient to notify nurse if pain especially of shoulder of neck, edema, unusual sensations, or redness at insertion site Apply digital pressure if bleeding from insertion site and call nurse Dressing must stay dry and intact 9.2 For outpatients: Do not allow dressing to become wet Notify physician if any pain, edema or redness occurs to exit site, or if arm, chest or neck pain is experienced on PICC side What to do in case of emergency (eg. short of breath) 9.3 Immediately after insertion apply warm compresses for hours intermittently to upper arm with catheter. 9.4 No blood work or blood pressure to arm with PICC. 9.5 Avoid excessive movement to arm with PICC. NO weightlifting or vigorous arm exercises. Normal daily activities are acceptable. 9.6 Avoid tight fitting sleeves that may constrict arm. 9.7 Scissors or clamps should not be used to remove dressings or around IV site/tubing. 9.8 Avoid any pressure on inner surface area or axilla of cannulated arm. If using crutches, do not press under arm with catheter DOCUMENTATION 10.1 Patient Care Record Record * integrity of site * complications of catheter * status of infusion * dressing changes, observation of insertion site, sutures (if applicable) 10.2 Infusion Therapy Record * volume and type of solution * initiation and discontinuation of therapy 10.3 Medication Administration Record * locking solution 10.4 Kardex if applicable * dates of planned equipment changes;

15 15 of 21 i.e. dressing change q7 days (eg. Oct. 9, 16, 23) Injection cap changes q96 hours (Oct. 9, 13, 17) 11.0 REMOVAL OF PICC 11.1 Removal of PICCs with malpositioned tip location should be considered PICCs may be removed by physician/np; or RN staff who have been observed by a clinical educator, manager, or designate and have successfully completed the Performance Criteria Checklist for PICC Removal may independently remove PICC lines 11.3 An order is required to remove a PICC. Ensure all IV medications/ solutions are discontinued by the prescriber, or that alternate IV access has been established The nurse removing the catheter should be prepared to initiate emergency measures as needed. Complications of removal include, but are not limited to: Air embolism Catheter embolism Pulmonary embolism Excessive bleeding Resistance to removal Equipment protective gloves and mask petroleum impregnated gauze hydrocolloid dressing Sterile outer dressing sterile gauze chlorhexidine2% with 70% isopropyl alcohol swab. Sterile scissors, gloves and container for C&S (if clinically indicated) Sterile scissors for SecurAcath removal 11.7 PROCEDURE Check chart for order Perform hand hygiene. Assemble equipment. Don mask. Don clean gloves and use hospital disinfectant to clean over-bed table or procedure table prior to opening sterile supplies. Remove gloves. Perform hand hygiene Verify patient identity using two identifiers, and explains procedure to patient. NURSING TIP: Venospasm is often the cause of difficult PICC removal. The following may prevent venospasm: decrease fear by teaching patient that removal will not hurt make sure patient is comfortable and relaxed

16 16 of 21 apply a warm blanket or compress to the upper extremity encourage the patient to drink warm liquids avoid excessive manipulation of PICC Place patient in supine or seated position. Position patient arm abducted at a angle and the exit site below the level of the heart Perform hand hygiene. Aseptically open equipment. Don clean gloves. NURSING ALERT: Precautions should be taken to prevent air embolism when a PICC is removed. Do not leave open to air post removal Remove dressing as per section Inspect exit site. NURSING ALERT: If purulent drainage at exit site, obtain swab for C&S from exit site. If purulent drainage is noted at exit site or systemic infection is suspected, following removal, cut approximately 5 cm of catheter tip with sterile scissors, while not allowing PICC tip to touch skin or unsterile equipment. Place tip in sterile container and send to lab for C&S Remove securement device from exit site. Exception: PICC must be removed prior to SecurAcath removal. Follow manufacturer s direction for removal of SecurAcath at Cleanse exit site with chlorhexidine swabstick Beginning at the exit site, pull slowly until catheter is removed. Do not apply pressure to exit site during removal. Using gentle and even pressure, slowly pull the catheter out, keeping the catheter parallel to the skin and re-grasping catheter at exit site as the catheter is removed.. Do not use force or apply tension. NEVER stretch the catheter. If slight resistance is felt, pause to allow the vein to relax before continuing. If firm resistance is encountered STOP. NURSING ALERT: A PICC may resist removal because of venous spasm, vasoconstriction, phlebitis, valve inflammation, or thrombosis. To reduce the risk of catheter breakage and/or embolism, if firm resistance is encountered during catheter removal: Release the catheter; cover the exit site with a temporary sterile dressing. Try relaxation/distraction techniques with patient. Apply a warm moist compress to exit site and upper arm for 30 minutes. Have

17 17 of 21 patient hold a warm object in the hand. After 30 minutes, attempt catheter removal. If catheter is still stuck, put sterile dressing on exit site and call physician. Wait an additional hours to allow spasm to abate before attempting to remove catheter again Once PICC has been removed, apply digital pressure with sterile gauze to exit site until hemostasis is verified (at least 30 seconds). Remove SecurAcath (if this is the securement device used) as per manufacturer s recommendation Apply an air and water occlusive dressing over insertion site. This may be a petroleum-based ointment/gauze that will seal the skin to vein tract and decrease the risk of air embolus or sterile gauze topped by a hydrocolloid dressing such as Comfeel that prevents air or fluid entry under dressing Examples of dressings are: Petroleum impregnated gauze dressings such as Adaptic, Vaseline, Xeroform topped with sterile gauze and transparent film Sterile gauze covered by hydrocolloid dressing. Note: Gauze and transparent dressing alone is not airtight. Change dressing daily until site reepithelialised Inspect catheter for length and integrity. Compare the length to the recorded length in the chart. NURSING ALERT: If the catheter is shorter than expected, save catheter (place in biohazard bag) and call the physician immediately so that a follow-up chest x-ray and physical examination can be done Dispose of PICC into biohazard container. IN CASE OF CATHETER BREAKAGE: Call for medical assistance immediately. Check vital signs and pulses every five minutes. Do not leave patient unattended. Do not allow patient to ambulate. Patient may be referred to an interventional radiologist or surgeon If catheter related blood stream infection is suspected, place sterile drape (from dressing tray) in close proximity to catheter-skin junction. Remove catheter as described above avoiding contact with surrounding skin. Using aseptic technique cut 5 cm of the catheter tip with sterile scissors and place in a sterile specimen container. Label with patient name and send to the lab for culture and sensitivity Observe the patient for signs and symptoms of insertion site bleeding and air embolism or pulmonary embolism (sudden onset of chest pain, dyspnea, unequal breath sounds, decreased O 2 saturations, cyanosis, hypotension, weak pulse, decreased LOC, churning cardiac murmur).

18 18 of DOCUMENTATION OF REMOVAL 12.1 Document removal procedure in patient record, indicating catheter integrity, if a swab or catheter tip was sent for culture, site appearance, dressing applied, patient tolerance and if any difficulties during removal were encountered. 13 COMPLICATIONS COMPLICATION SIGNS & SYMPTOMS ACTION PREVENTION AIR EMBOLISM * coughing, chest pain, respiratory distress, sob * cyanosis * altered level of consciousness ARTERIAL PUNCTURE BRACHIAL PLEXUS INJURY CATHETER OCCLUSION DAMAGED CATHETER * pulsating blood return * blood backing up into tubing during infusion * tingling of fingers, pain shooting down arm and/or paralysis * Unable to aspirate blood withdrawal occlusion * unable to inject or infuse solution total occlusion * leaking of fluid or blood from insertion site * leaking of fluid or blood at damaged area * stop infusion(s) * clamp or pinch catheter (above damaged area) * patient to lie on left site in Trendelenberg position * begin resuscitation procedure if required. Notify physician/np * administer O 2 monitor V/S * apply pressure over puncture site * begin resuscitation procedures if required * notify physician/np immediately * Always clamp catheter before opening. Have patient perform Valsalva Manoeuvre. * Remove all air from tubing and syringes. * Use leur lock connections - ensure they are tight. * Have non-toothed clamp available. * Occurs inadvertently during insertion. * notify physician/np * Occurs inadvertently during insertion. * attempt to aspirate then attempt to flush the catheter (do not apply force when flushing) * notify physician/np * manage the occlusion or remove catheter * stop infusion * do not use catheter * clamp catheter with a nonserrated clamp proximal to the damaged area * notify physician/np * Use positive pulsing pressure when flushing/locking * Flush/lock lumens at recommended intervals. * Clamp catheter when not in use for open ended catheters. * Never use scissors or sharp objects around catheter. * Use 10 ml syringes or syringe barrels manufactured to reduce infusion pressure (BD Posiflush ) when flushing to prevent catheter rupture.

19 19 of 21 COMPLICATION SIGNS & SYMPTOMS ACTION PREVENTION * Never use force when flushing. * Unclamp before flushing. * Keep catheter securely taped. * Vary position of clamps along lumen. INFECTION * redness, pain, warmth, swelling around exit site, drainage (purulent, discoloured) * fever and chills * generalized malaise * elevated WBC MALPOSITION * difficulty with aspiration or infusion * discomfort in neck or arm * edema of neck or shoulder * longer external length * ear gurgling sound described during infusion * arrhythmias (if in right atrium) THROMBOSIS * upper chest pain, jaw pain, ear ache * swelling of arm, neck and shoulder on same side a catheter * sluggish flow of IV solution * do not use catheter * notify physician/np immediately Obtain simultaneous blood cultures from a peripheral site and each lumen of the CVC. * do not use catheter * inform physician/np * CXR * do not use catheter * notify physician/np * Perform hand hygiene & wear clean gloves before handling catheter or equipment. * Maximum barrier precautions at insertion * Strict aseptic technique. * Change dressings and equipment according to procedure and prn; i.e. soiled, loose, damp. * Minimize accessing catheter. * Remove catheter when therapy complete * Ensure catheter and tubing secured. * Monitor catheter insertion length with dressing changes, each shift and prn. * Ensure PICC not accidentally withdrawn during dressing changes. NEVER push PICC back into vein. * Monitor for signs and symptoms and report. * Avoid trauma or movement of catheter. * Obtain order for Venous Doppler to rule out DVT

20 20 of 21 COMPLICATION SIGNS & SYMPTOMS ACTION PREVENTION SUPERIOR VENA CAVA SYNDROME Catheter Embolism * progressive shortness of breath, dyspnea, cough, chest skin tightness; unilateral edema, cyanosis of face, neck, shoulders and arms; jugular, temporal and arm vein distension As for air emboli. Observe for ruptured / damaged /broken catheter. * notify physician/np immediately at first signs and symptoms * place in semi-fowlers position and start oxygen at 2 L/min. * provide emotional support * monitor cardiovascular and neurologic status Notify physician/np. * Monitor for signs and symptoms. Cause is due to flushing against resistance, or excess stretching of catheter with movement/ambulation

21 21 of 21 Appendix A PICC DRESSING CHANGE PRINCIPLES A clean and dry dressing at the insertion site is important to protect the site and to minimize the risk of infection. Know the external length of catheter at the time of insertion, so that you can determine if the catheter has been accidentally malpositioned during the dressing change. Each black dot indicates 1 cm. If malposition is suspected, obtain order for chest x-ray. SecurAcath is 3 cm long. NEVER push PICC back into insertion site Change dressing if damp, loosened, or soiled and at scheduled times. Wear clean gloves: to remove transparent film dressings; to remove PICC from StatLock to remove the StatLock device from the skin Hand hygiene then don sterile gloves Wear sterile gloves prior to touching any part of the newly cleansed catheter or skin, and for replacing a new sterile StatLock device Wear Clean or sterile gloves to clean skin and external catheter that will be under the new dressing Wear a mask to prevent site contamination with mouth bacteria Cleanse by using a back and forth, and up and down motion with gentle friction for at least 30 seconds. Chlorhexidine products requires an application time of at least of 30 seconds with friction to be effective Let cleansers dry: Allow all cleansers and barrier films to thoroughly air dry. No fanning, blowing, or drying with gauze. It must air dry completely (1-6 minutes) prior to applying any other product. Applying barrier film or adhesives when the antiseptic solution is still wet will result in skin irritation. Loosely apply transparent dressing over the insertion site and catheter then apply pressure at the insertion site and over the catheter to establish adhesion to the skin and catheter. Note: Do not stretch the transparent film while applying the dressing because this may cause skin stripping and/or blister formation at the dressing edges. Do not use scissors to remove tape or dressings as the catheter may be accidentally cut. Use an assistant for confused and uncooperative patients who may accidentally remove their catheter. The risk and cost of replacing the catheter outweighs the cost of using two staff members.

22 Performance Criteria StatLock PICC Dressing 1. Performs hand hygiene and collects materials 2. Performs hand hygiene prior to entering patient/resident room 3. Identifies self to patient/resident 4. Confirms patient/resident ID with 2 identifiers (has patient/ resident actively involved in identification if possible) 5. Explains procedure to patient/resident 6. Dons mask. Perform hand hygiene & dons clean gloves. Cleans work area with low level disinfectant and allow to air dry. Removes gloves. Performs hand hygiene. 7. Opens packages onto sterile tray keeping all supplies sterile. OK to open and arrange packages on edge of sterile field. 8. Dons clean gloves 9. Removes old dressing ensuring PICC line stabilized 10. Using a chlorhexidine and alcohol swabstick, removes the StatLock. Suture wing may be held to ensure PICC is not accidentally removed. Extension taped so that PICC does not accidentally migrate out, but allows for cleansing of skin and external catheter. 11. Either clean or sterile gloves may be used to clean skin and external catheter. If sterile gloves chosen, remove clean gloves, perform hand hygiene and don sterile gloves. 12. Cleanses skin that will be covered by the dressing in a back and forth motion using friction. Then cleanses using the other side of swabstick using an up and down motion with friction. Chlorhexidine requires contact for at least 30 seconds to be effective. 13. Using a new swabstick cleanses along external catheter from insertion site up to and including suture wing. Using the other side of the swabstick, cleanses along the underside of the external catheter and suture wing. 14. If sterile gloves worn and catheter needs to be moved gloves may be protected with sterile gauze. Caution: if gauze becomes wet considers gloves contaminated. 15. Allows chlorhexidine/alcohol to dry completely (1-6 minutes) 16. Applies barrier wipe staying 1cm away from insertion site (not to be used on broken skin or under chlorhexidine dressing /patches ) 17. Counts all markings (one dot equals 1 cm compare with original length, if discrepancy exists x- ray placement verification prior to use) 18. Sterile gloves required. Places PICC in stabilizing device and positions prior to removing tape backing. Adhere stabilizing device to skin. 19. Replaces Steri-Strips if required only on catheter suture wing. 20. Loosely applies transparent dressing covering insertion site, securement device and all exposed catheter including suture wing. Extension does not need covering. 21. Label: date and initial 22. Removes gloves and performs hand hygiene 23. Trouble-shoots common problems effectively 24. Provides patient teaching 25. Tidies work area 26. Performs hand hygiene prior to leaving patient/resident room 27. Documents procedure and patient/resident teaching outcomes Date Staff Member Observed By/Designation Met Not Met Print name Print name Signature Signature Comments PICC Dressing & Q96H Cap Change Performance Checklists 1 of 3

23 Performance Criteria SecurAcath PICC Dressing 1. Performs hand hygiene and collects materials 2. Performs hand hygiene prior to entering patient/resident room 3. Identifies self to patient/resident 4. Confirms patient/resident ID with 2 identifiers (has patient/resident actively involved in identification if possible) 5. Explains procedure to patient/resident 6. Dons mask. Perform hand hygiene & dons clean gloves. Cleans work area with low level disinfectant and allow to air dry. Removes gloves. Performs hand hygiene. 7. Opens packages onto sterile tray keeping all supplies sterile. OK to open and arrange packages on edge of sterile field. 8. Dons clean gloves 9. Removes old dressing ensuring PICC line stabilized 10. Either clean or sterile gloves may be used to clean skin and external catheter. If sterile gloves chosen, remove clean gloves, perform hand hygiene and don sterile gloves Using chlorhexidine cleanses skin that will be covered by the dressing in a back and forth motion using friction. Then cleanses using the other side of swabstick using an up and down motion with friction. Chlorhexidine requires contact for at least 30 seconds to be effective. 12. Using a new swabstick cleanses along external catheter, soaks SecurAcath, then from insertion site up to and including suture wing. Using the other side of the swabstick, cleanses the underside of the external catheter, SecurAcath and suture wing. 13. If sterile gloves worn and catheter needs to be moved gloves may be protected with sterile gauze. Caution: if gauze becomes wet considers gloves contaminated. 14. Allows chlorhexidine/alcohol to dry completely (1-6 minutes) 15. Applies barrier wipe staying 1cm away from insertion site (not to be used on broken skin or under chlorhexidine dressing /patches ) 16. Counts all markings (one dot equals 1 cm compare with original length, if discrepancy exists x-ray placement verification prior to use) 17. Replaces Steri-Strips if required only on catheter suture wing. 18. Loosely applies transparent dressing covering insertion site, securement device and all exposed catheter including suture wing. Extension does not need covering. 19. Label: date and initial 20. Removes gloves and performs hand hygiene 21. Trouble-shoots common problems effectively 22. Provides patient teaching 23. Tidies work area 24. Performs hand hygiene prior to leaving patient/resident room 25. Documents procedure and patient/resident teaching outcomes Met Not Met Date Staff Member Observed By/Designation Print name Print name Signature Signature Comments PICC Dressing & Q96H Cap Change Performance Checklists 2 of 3

24 Performance Criteria Every 96 hours Injection Cap change 1. Performs hand hygiene and collects materials 2. Performs hand hygiene prior to entering patient/resident room 3. Identifies self to patient/resident 4. Confirms patient/resident ID with 2 identifiers (has patient/ 5. resident actively involved in identification if possible) 6. Explains procedure to patient/resident 7. Cleans work area with low level disinfectant and allow to air dry 8. Performs hand hygiene and dons clean gloves 9. Cleans around the cap/hub junction for 15 seconds with wipe containing alcohol or chlorhexidine with alcohol and allows to dry 10. Closes clamp if applicable 11. Using no touch technique removes cap and replaces with sterile cap. 12. Scrubs hub of cap with antiseptic wipe then flushes with normal saline. Scrubs hub again and locks PICC with ordered locking solution. Note: if normal saline is the locking solution, the second injection is not required. 13. Removes gloves and performs hand hygiene 14. Trouble-shoots common problems effectively 15. Provides patient teaching 16. Tidies work area 17. Performs hand hygiene prior to leaving patient/resident room 18. Documents procedure and patient/resident teaching outcomes Met Not Met Date Staff Member Observed By/Designation Print name Print name Signature Signature Comments PICC Dressing & Q96H Cap Change Performance Checklists 3 of 3

25 PICC Removal Demonstration Checklist Removing PICC 1. Ensures patient care order for PICC removal. Ensures all IV medications/solutions have been discontinued, or alternate IV site established. 2. Perform hand hygiene. Assemble equipment. Don mask. Don clean gloves and use hospital disinfectant to clean over-bed table or procedure table prior to opening sterile supplies. Remove gloves. Perform hand hygiene. 3. Identifies and teaches patient. Positions patient. Position patient arm abducted at a angle and the exit site below the level of the heart. 4. Performs hand hygiene. Using aseptic technique opens sterile equipment. Dons clean gloves. 5. Removes dressing. Inspects site. If purulent drainage is noted, is prepared to obtain swab and 5 cm catheter for C&S. 6. Removes StatLock device if applicable. Remove top part of SecurAcath. Note: Remainder of SecurAcath removed after PICC removed. Cleanses skin over insertion site. 7. Beginning at exit site, and using gentle, even pressure slowly removes PICC. If resistance encountered, pauses procedure to allow vein to relax. If firm resistance is encountered, stops procedure and covers PICC with new sterile dressing and performs steps to reduce Venospasm (12.7). 8. Once PICC removed, applies digital pressure until homeostasis is confirmed. If applicable removes SecurAcath at this time as per manufacturer s instructions (see video). If applicable, obtains tip for culture as per procedure ( ). 9. Applies air occlusive dressing: Uses petroleum gauze, sterile gauze and transparent film; or sterile gauze and hydrocolloid dressing to site. 10. Inspects PICC for length and integrity. Disposes of PICC. 11. Trouble-shoots common problems effectively. 12. Provides patient teaching. 13. Tidies work area. 14. Performs hand hygiene prior to leaving patient/resident room. 15. Documents procedure and patient/resident teaching outcomes. Demonstrated Correctly Yes No May perform skill independently Please repeat Observer Signature May 2016

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