corporate policy & procedures care and removal of manual...

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

Corporate Policy & Procedures

Manual

Number: VII-B-305

Date Approved August 9, 2017

Approved by: Vice President and Chief Medical Officer; and Vice President and Chief Operating Officer

Date Effective September 15, 2017

Next Review (3 years from Effective Date)

September 2020

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 PICCs. All PICCs 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, members of the medical staff, 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 (CLABSI) Using infection prevention maintenance bundles decreases CLABSI Indications for use of central venous catheters:

Administration of medications, such as chemotherapy or antibiotics

Administration of fluids, including blood components or blood products


Date Effective Sept. 15, 2017

Policy No. VII-B-305

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Monitoring of central venous pressure

Providing parenteral nutrition 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

See Demonstration Skills Checklists

Performance Criteria StatLock™ PICC Dressing

Performance Criteria SecurAcath™ PICC Dressing

Performance Criteria Every 96 hours Needleless connector change

PICC Removal Demonstration Checklist

Definitions For the purpose of this policy and procedure: Scrub the hub means: Each time the needleless connector is entered it must be cleaned with an alcohol or chlorhexidine/alcohol swab. Scrub the needleless connector with the swab 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 Needleless connector change

PICC Removal Demonstration Checklist




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References Alexander, M., Corrigan, A., Gorski, L., Hankins, J., Perucca, R. Infusion Nurses Society: Infusion Nursing: An evidence-based Approach. 3rd Edition. 2010

Centres for Disease Control and Prevention. (2011). Guidelines for the prevention of intravascular catheter-related infections, 2011. Self-published.

Doellman, D. et al (2009). Infiltration and Extravasation: Update on prevention and management. Journal of Infusion Nursing. Vol. 32, No. 4.

Gorski, L., Hadaway, L., Hagle, M., McGoldrick, M., Meyer, B., & Orr, M. (2016). Policies and Procedures for Infusion Therapy.

Gorski, L., Hadaway, L., Hagle, M. E., Friedman, M. M., Orr, M., & Doellman, D. (2016). Infusion therapy: standards of practice. Norwood, MA: Journal of Infusion Nursing.

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).

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 2012.

The Joint Commission, J Preventing central line-associated bloodstream infections: a global challenge, al global perspective. Oak Brook IL: Joint commission resources, May 2012. http://www.Preventing CLABSIs.pdf.

International evidence-based recommendations on ultrasound-guided vascular access. Intensive care medicine, Published online 22 May 2012.

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):287-292

Hadaway L. Heparin locking for central venous catheters. Journal of Association for Vascular Access. 2006; 11 (4): 224-231

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 21 2007; 22(11):38-44.

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):610-613

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):67-70.

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

http://www.preventing/




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Previous Version (date)

July 11, 2014




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PROCEDURE

INDEX

1.0 INFECTION PREVENTION & CONTROL ............................................................ 6

2.0 PATIENT SAFETY ............................................................................................... 6

3.0 ENSURING PATENCY & FLUSHING PICC ......................................................... 7

4.0 GUIDELINES FOR LOCKING PICC .................................................................... 8

4.1 Open-ended PICCs .......................................................................................... 8

4.2 Closed ended / valved PICCs .......................................................................... 9

5.0 NEEDLELESS CONNECTOR CHANGE ............................................................. 9

6.0 PICC DRESSING CHANGE USING STATLOCK® SECUREMENT .................... 9

7.0 PICC DRESSING CHANGE USING SECURACATH SECUREMENT ............... 12

8.0 PATIENT ASSESSMENT ................................................................................... 14

9.0 PATIENT TEACHING......................................................................................... 15

9.1 For inpatients: ................................................................................................ 15

9.2 For outpatients: ............................................................................................. 15

10.0 DOCUMENTATION ............................................................................................ 15

11.0 REMOVAL OF PICC .......................................................................................... 16

12.0 DOCUMENTATION OF REMOVAL ................................................................... 19

13.0 COMPLICATIONS ............................................................................................. 19

Apendix A: PICC DRESSING CHANGE PRINCIPLES ............................................. 22




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1.0 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. needleless connector 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 a needleless connector to lumen ends. Attach

administration sets to the needleless connector.

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 swab before they are accessed. Scrub the hub for 15 seconds and allow solution to dry completely.

2.0 PATIENT SAFETY 2.1 Proper maintenance of PICC is essential for continued patient safety.

2.2 Daily assessment of line necessity:

2.2.1 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;

2.2.2 Catheters that are no longer needed should be promptly removed.




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2.2.3 Daily review of the continued need for CVADs 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: 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 Don non-sterile gloves. Scrub the hub. Ensure catheter patency by using a 10 mL syringe with NS to instil 1-2 mL of NS using positive pulsing pressure. Aspirate for brisk blood return, and flush the remainder of the NS 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, 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 needleless connector / administration set changes and prn

Intermittent infusions: prior to administration of flush solution / medication

PICCs not in use: with daily locking solution administration.




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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

After infusion of viscous solution (i.e. TPN)

Prior to collecting a specimen for drug levels 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

4.1.1 Maintain the patency of each unused lumen by locking each lumen post infusion, and as per Vascular Access Device Quick Reference Protocol Locking solutions, in order of preference are:

1. 3 mL sodium citrate 4% 2. 5 mL of heparin lock solution (10 units/mL) or, if not available, 3. 3 mL heparin lock solution (100 units/mL)

4.1.2. Inject locking solution slowly over 3-5 seconds 4.1.3 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).

4.1.4 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.




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4.1.5 If the PICC has a clamp, it must be clamped when not in use with the clamp provided. Vary position of clamp along lumen to prevent wearing of catheter lumen. If clamp has fallen off, obtain replacement clamp if possible and attach to CVAD extension.

4.2 Closed ended / valved PICCs

(Groshong / Solo / Neutral displacement connector)

4.2.1 Maintain the patency of each lumen by locking with 10 mL of normal saline for injection lumen post infusion, and as per Vascular Access Device Quick Reference Protocol

The volume should be at least twice the volume capacity of the catheter lumen plus the priming volume of all add-on devices (eg. Needleless connector, 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 NEEDLELESS CONNECTOR 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 needleless connectors and/or extension sets. If the clamp has fallen off, have the patient exhale while changing the connector. Replace clamp if possible.

5.2 Cleanse the connection between the catheter hub and needleless connector with antiseptic

swab for 15 seconds. Using no touch technique, remove the old needleless connector and replace with a new sterile needleless connector taking care not to touch the threads of the catheter hub or to contaminate the threads of the new sterile connector. Some needleless connectors require priming prior to attaching to PICC, therefore follow cap manufacturer’s directions. If threads of catheter hub are dirty, prior to attaching new needleless connector, cleanse hub threads with chlorhexidine alcohol swab being careful that cleansing solution does not enter catheter.

5.3 Change needleless connectors as per Vascular Access Device Quick Reference Protocol or if

removed, soiled, broken or blood in connector.

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. CavilonTM 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




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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

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 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.




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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.

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. CavilonTM 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.




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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.

6.10 Ensure arm is fully extended; apply 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.

6.11 Label dressing with your initials and the date the dressing was changed. 6.12 Change dressings as per Vascular Access Device Quick Reference Protocol, or if soiled, damp,

or loose.

Gauze under a transparent dressing is considered gauze dressing and must be changed as such.

Initial dressing upon insertion with gauze must be changed 24 hours post insertion unless orders suggest otherwise.

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. CavilonTM 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




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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 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. CavilonTM 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.




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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.

7.8 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 your initials and the date the dressing was changed. 7.10 Change dressings as per Vascular Access Device Quick Reference Protocol,or if soiled, damp,

or loose.

Gauze under a transparent dressing is considered gauze dressing and must be changed as such.

Initial dressing upon insertion with gauze must be changed 24 hours post insertion unless orders suggest otherwise.

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.




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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.

9.0 PATIENT TEACHING

9.1 For inpatients:

9.1.1 Reinforce to patient to notify nurse if pain – especially of shoulder of neck, edema, unusual sensations, or redness at insertion site.

9.1.2 Apply digital pressure if bleeding from insertion site and call nurse. 9.1.3 Dressing must stay dry and intact

9.2 For outpatients:

9.2.1 Do not allow dressing to become wet. 9.2.2 Notify physician if any pain, edema or redness occurs to exit site, or if arm, chest or neck

pain is experienced on PICC side. 9.2.2 What to do in case of emergency (eg. short of breath)

9.3 Immediately after insertion apply warm compresses for 24 - 48 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.

10.0 DOCUMENTATION

10.1 Patient Care Record Record

* integrity of site * complications of catheter




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* 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;

i.e. dressing change q7 days (eg. Oct. 9, 16, 23) Needleless connector changes q96 hours (Oct. 9, 13, 17)

11.0 REMOVAL OF PICC

11.1 Removal of PICCs with malpositioned tip location should be considered.

11.2 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.

11.4 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.

11.5 Equipment

Protective gloves and mask

Petroleum impregnated gauze

Hydrocolloid 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 as required




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11.6 PROCEDURE

11.6.1 Check chart for order.

11.6.2 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.

11.6.3 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

apply a warm blanket or compress to the upper extremity

encourage the patient to drink warm liquids

avoid excessive manipulation of PICC

11.6.4 Place patient in supine or seated position. Position patient arm abducted at a 45-90°

angle and the exit site below the level of the heart. 11.6.5 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.

11.6.6 Remove dressing as per section 11.

11.6.7 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.

11.6.8 Remove securement device from exit site. Exception: PICC must be removed prior to SecurAcath removal. Follow

manufacturer’s direction for removal of SecurAcath at http://www.interradmedical.com/removal

11.6.9 Cleanse exit site with chlorhexidine swabstick.

11.6.10 Beginning at the exit site, pull slowly until catheter is removed.

Do not apply pressure to exit site during removal.

http://www.interradmedical.com/removal




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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 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 12 – 24 hours to allow spasm to abate before attempting to remove catheter again.

11.6.11 Once PICC has been removed, apply digital pressure with sterile gauze to exit site until

hemostasis is verified (at least 30 seconds). 11.6.12 Remove SecurAcath (if this is the securement device used) as per manufacturer’s

recommendation

11.6.13 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.

11.6.14 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.

11.6.15 Dispose of PICC into biohazard container.




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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.

11.6.16 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.

11.6.17 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 O2 saturations, cyanosis, hypotension, weak pulse, decreased LOC, churning cardiac murmur).

12.0 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.

13.0 COMPLICATIONS

COMPLICATION SIGNS & SYMPTOMS ACTION PREVENTION

AIR EMBOLISM * coughing, chest pain, respiratory distress, sob

* cyanosis * altered level of

consciousness

* 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 O2 monitor V/S

* 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.

ARTERIAL PUNCTURE

* pulsating blood return * blood backing up into

tubing during infusion

* apply pressure over puncture site

* begin resuscitation procedures if required

* notify physician/NP immediately

* Occurs inadvertently during insertion.

BRACHIAL PLEXUS

* tingling of fingers, pain shooting down arm and/or

* notify physician/NP * Occurs inadvertently during insertion.




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INJURY paralysis

CATHETER OCCLUSION

* Unable to aspirate blood – withdrawal occlusion

* unable to inject or infuse solution – total occlusion

* leaking of fluid or blood from insertion site

* attempt to aspirate then attempt to flush the catheter (do not apply force when flushing)

* notify physician/NP

* manage the occlusion or remove catheter

* Use positive pulsing pressure when flushing/locking

* Flush/lock lumens at recommended intervals.

* Clamp catheter when not in use for open–ended catheters.

DAMAGED CATHETER

* leaking of fluid or blood at damaged area

* stop infusion * do not use catheter * clamp catheter with a non-

serrated clamp proximal to the damaged area

* notify physician/NP

* 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.

* 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

* do not use catheter * notify physician/NP

immediately

Obtain simultaneous blood cultures from a peripheral site and each lumen of the CVAD.

* 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




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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)

* do not use catheter * inform physician/NP

* CXR

* 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.

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

* Monitor for signs and symptoms and report.

* Avoid trauma or movement of catheter.

* Obtain order for Venous Doppler to rule out DVT

SUPERIOR VENA CAVA SYNDROME

* progressive shortness of breath, dyspnea, cough, chest skin tightness; unilateral edema, cyanosis of face, neck, shoulders and arms; jugular, temporal and arm vein distension

* 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

* Monitor for signs and symptoms.

Catheter Embolism

As for air emboli.

Observe for ruptured / damaged /broken catheter.

Notify physician/NP. Cause is due to flushing against resistance, or excess stretching of catheter with movement/ambulation




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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.