guidelines for the insertion and management of

Guidelines for the Insertion and Management of Peripherally Inserted Central Catheters (PICC) in Adult

Haematology and Oncology Patients

Version Three

Date of Publication: June 2005 Oct 2011

February 2013

Author: Sam Neale, Lead Chemotherapy Advanced Nurse Practitioner

Name of responsible committee/individual:

Arden Cancer Network Chemotherapy Cross-Cutting Group

Target audience:

Haematology & Oncology Practitioners

Date of Ratification: 7th March 2013

Ratified by: Chair of the Arden Cancer Network and the Executive Group

Date for Review: Oct 2014

Guidelines for the Insertion and Management of Peripherally Inserted Central Catheters (PICC) in Adult Haematology and Oncology Patients

Version Three 2 of 45

Version History

Version Date Brief Summary of Change 3 February 2013 Wording changed relating to the use of Hepsal

2 October 2011 References Updated

Changes to type of Skin Prep used.

Changes to type of solution used to clean catheter hub.

Terminology changed to generic.

1 July 2005



Contents

Section Page

1.0 Introduction 4

2.0 Purpose 4

3.0 General guidance for PICC Lines 4

4.0 Consultation and Communication Process 8

5.0 Equality Impact Assessment 8

6.0 Review and Revision Arrangements including Version Control 8

7.0 Dissemination and Implementation 8

8.0 References 9

9.0 Document Circulation 10

Appendices

Appendix A

Procedure for the Insertion of a PICC Line 14

Appendix B

Procedure for Withdrawing a PICC Line

20

Appendix C

Procedure for Taking blood samples from a PICC Line 22

Appendix D

Procedure for Maintaining Patency (Flushing) of a PICC Line 25

Appendix E

Procedure for the Administration of Intravenous Drugs via a PICC Line

28



Section Page

Appendix F

Appendix G

Appendix H

Appendix I

Appendix J

Procedure for Dressing a PICC Line

Procedure for Unblocking an Occluded Skin-Tunnelled Catheter (Hickman Line)

Procedure for the Management of Persistent Withdrawal Occlusion of Skin-Tunnelled Catheter (Hickman Line)

Procedure for the Removal of a Peripherally Inserted Central Catheter (PICC)

Equality Impact Assessment Tool

32

35

39

40

42

Appendix K

Plan for Dissemination 44



1. Introduction

This Guideline was developed by the Arden Cancer Network Chemotherapy Group incorporating; Alexandra Hospital (part of Worcestershire Acute Hospitals NHS Trust), George Eliot Hospital NHS Trust, South Warwickshire NHS Foundation Trust and University Hospitals Coventry and Warwickshire NHS Trust (UHCW) with support from individual Trust’s chemotherapy groups. It has been specifically developed for health professionals working within the fields of oncology and haemato-oncology but is applicable to any health professional who may be involved in the insertion or management of a Peripherally Inserted Central Catheter (PICC line). 1. Definition A Peripherally Inserted Central Catheter (PICC) is an intravenous device inserted via the veins of the antecubital fossa – usually the basilic or cephalic veins. The catheter is advanced into the central veins with the tip located within the superior vena cava just above the right atrium (Gabriel 2005, Vesley 2003).

2. Purpose The overall aim of a Peripherally Inserted Central Catheter is to improve the quality of life of the patient by:

Reducing the need for repeated venepuncture and cannulation.

Reducing the risk of extravasation of vesicant drugs.

Providing an alternative means of intravenous access for those patients who may be anxious or needle phobic.

Providing an alternative means of intravenous access to allow the patient to receive drug treatments at home, or elsewhere in the community, thus reducing the need for inpatient stays.

PICC lines have many advantages over other types of central venous access devices e.g. less risk of complications on insertion, reduced rates of infection.

3. Principles of Care 3.1 Clinical Criteria Patients with the following criteria are likely to be suitable for a PICC line:

Lack of peripheral access.

Infusions of vesicant, irritant, parenteral nutrition or hyperosmolar solutions.

Long-term venous access required.

Patient preference.

Patients with needlephobia, to prevent repeated cannulations.

Clinician preference if patients are at risk of haemorrhage or pneumothorax from insertion of centrally-inserted catheters.



3.2 Contraindications

The inability to locate suitable antecubital veins.

Anatomical distortions from surgery, injury, or trauma.

Patient is unable to lie supine.

Patient is confused, unsafe to have a central venous access device. 3.3 Management and Care The safe maintenance of a PICC Line and relevant care of the insertion site are essential components of a guideline for preventing infections. This includes good practice in caring for the patient’s catheter hub and connection port, the use of an appropriate PICC line dressing regimen, and using flushing solutions to maintain the patency of the PICC line. This can be achieved by:

Using a non-touch technique, to prevent infection and sepsis, (Pratt et al. 2007).

Maintaining a closed system, thus preventing blood loss or air embolism.

Maintaining catheter patency to prevent occlusion.

Preventing accidental damage or dislodgement.

Education patient in self care of their catheter.

3.4 Training of staff Any member of staff who is involved in either PICC placement or the management of PICC lines will have a period of training and supervised practice will be arranged and monitored by each Trust according to their own local procedures this will include:

Undertaking an appropriate programmed of education as defined by their Trust (Pratt et al. 2007).

Ensure that they have reached a level of competence following a period of supervised practice (Pratt et al. 2007).

Ensure that they have been assessed as competent prior to performing this skill without supervised practice (Pratt et al. 2007).

Each practitioner is accountable to ensure that they maintain and develop their knowledge and skills and clinical competency in the insertion and management of a peripheral central catheter (NMC 2008). If it is not practiced on a regular basis the practitioner is advised to revisit the training package.

3.5 Preparation of the Patient for Catheter Insertion

The practitioner inserting the PICC line will explain the procedure to the patient, provide written information on ‘PICC Line Insertion’ and will obtain informed written consent (Department of Health 2009).

The inserting practitioner will ensure the following blood tests are undertaken: full blood count and clotting screen.



Patients who are thrombocytopenic may need a platelet transfusion immediately prior to insertion; this will be requested and prescribed by the medical staff. Current guidelines suggest the platelet count should be at least 50x109/l (British Committee for Standards in Haematology 2003).

Local anesthetic cream may be applied to potential sites as per manufacturer’s recommendations. This must be prescribed or be under the direction of a Patient Group Directive.

If removal of hair from the arm is indicated, this should be accomplished using scissors or clippers with a disposable head (Dougherty & Watson 2008, Hart 2008b), depilatory cream is not recommended because of the potential for allergic reaction or irritation (RCN 2005, Perucca 2001), shaving with a razor is also not recommended since this has the potential for causing micro abrasions which increase the risk of infection (Perucca 2001, RCN 2010). Electric razors should have disposable heads for single-patient use (Carlson 2001)

Localized cleansing is required immediately prior to catheter insertion. Chlorhexidine 2% with 70% alcohol should be applied and allowed to dry. This is the most effective agent (Pratt et al. 2007).

Strict asepsis must be maintained throughout the insertion procedure.

Venous access for placement of the PICC should ideally be below or above the anticubital fossa using the cephalic, basilica or median cubital fossa veins (RCN 2010, Dougherty et. al. 2004).

3.6 Insertion of Catheter

Site selection: In selecting an appropriate insertion site, assess the risks for infection against the risks of mechanical complications. The cephalic, basilica or median cubital veins of the adult’s patient’s arms can be used for the insertion of a PICC (RCN 2010, Dougherty et. al. 2004).

The type of device inserted should be dependent on the length of therapy, the type of medication, the patient’s condition and preference (RCN 2010, Hamilton 2000).

A single-lumen PICC line should be used unless multiple lumens are essential for the management of the patient (Pratt et al. 2007).

Use maximal sterile barriers, including a sterile gown, sterile gloves, and a large sterile drape, for the insertion of a PICC line.

3.7 Immediate Management of the Patient Post Catheter Insertion

Patients must be assessed for signs and symptoms of pain. A mild analgesia is sometimes required, though occasionally stronger analgesics are needed (RCN 2010).

Following insertion, the PICC line must be flushed with 5-10ml sodium chloride 0.9% and then if recommended by the Manufacturer heparinised saline 50units in 5ml (Hepsal) as prescribed by the doctor/non-medical prescriber, using a positive pressure flush. This will maintain patency and reduce bacterial colonization (Pratt et



al. 2007, DoH 2001).

The PICC line should be secured with sterile steristrips or Statlock™ device and a sterile semi-permeable transparent dressing applied. This will aid comfort and to prevent dislodgement (RCN 2010, Gabriel 1999).

Following insertion, the initial gauze dressing and sterile semi-permeable transparent dressing should be left for 24 - 48 hours unless becomes soiled or absorbed, after this time the dressing should be changed routinely or immediately if the integrity of the dressing is compromised (NICE 2003). If the site is still oozing, replace with a new sterile gauze dressing and sterile semi-permeable transparent dressing and evaluate 24 hours later (Pratt et al. 2007, London Standing Conference 2002,).

A needle-less cap must seal the end of the catheter. This will ensure that the line is adequately sealed, minimizes the risk of air embolism or haemorrhage, ensures that a positive pressure flush is maintained to guarantee patency and reduces the risk of introducing and transferring organisms.

The needle-less cap must be replaced each time it is disconnected from the catheter, after 100 accesses, or at least every 7 days, or as per manufacturer’s guidelines.

As image intensification is rarely used in insertion of PICC Lines a chest x-ray must be performed before the line can be used. This will be checked by a doctor and the results recorded in-patients medical notes, prior to using the PICC line. The tip of the PICC line should lie within the superior vena cava (Philpot & Griffiths 2003). This may need to be manipulated to ensure correct positioning (Appendix 2).

Note: No line should be used, unless the X-ray has been checked and documented in the medical notes that the line is in the correct position for use.

3.8 Ongoing Management of Patients Post Catheter Insertion

An aseptic non-touch technique (ANTT) must be used for catheter site care and for accessing the PICC line (Pratt et al. 2007, NICE 2003). This will help to prevent the introduction of organisms to the line. A strong correlation exists between bacteraemia and the presence of a central venous line (DoH 2001) although other factors such as poor handling technique and general hygiene will affect line infection rates.

Before accessing or dressing a line, hands must be decontaminated as per Trust Policy or either by washing with antimicrobial liquid soap and water, or by using an alcohol hand rub, using the correct technique. (Pratt et al 2007).

Accessing PICC lines should always be kept to a minimum, by co-ordination of drug regime, intravenous infusions and blood taking (RCN 2005). This will reduce the risk of introducing and transferring organisms.

The use of sterile powder free gloves should be employed for all site care of central venous access devices (Pratt et al. 2007, DH 2001).



3.9 Using the Catheter

The hub of the catheter must be cleaned with an individual Chlorhexidine 2% with 70% alcohol wipe prior to use. (Pratt et al 2007, Saving Lives 2007)

The smallest syringe to be used on any catheter is a 10ml syringe. Use of a smaller sized (< 10ml) syringe when flushing or declotting a vascular access device risks PICC rupture or separation by exceeding the maximum pressure rating of the device (RCN 2005).

Prior to blood sampling (Appendix 3), flushing (Appendix 4) or administration of an intravenous drug (Appendix 5) via the line, 5ml of blood should be withdrawn from the lumen in use (this should be discarded unless taking blood for blood cultures). This will remove any organisms present within the line and reduce blood sample contamination with heparin. (RCN 2005).

The PICC line must be flushed with at least 20mls of a compatible infusion fluid in-between each drug administered (NICE 2003, DOH 2001).

Following use, the PICC line must be flushed with a minimum of 10mls 0.9% sodium chloride, and then heparinised saline to maintain patency and reduce bacterial colonization (DoH 2001), as prescribed by the doctor. The flush should be performed using a pulsated push-pause and positive pressure method. The pulsated flush creates turbulence with the device lumen, removing debris from the internal device wall (Gabriel et al., 2005). Positive pressure within the lumen of the device should be maintained to prevent reflux of blood (Infusion Nurses Society 2006) using the correct technique (Gabriel et al. 2005)

Patients at home or not having regular use of their PICC line must have their line flushed once per week using 10mls 0.9% sodium chloride and then if recommended by the Manufacturer heparinised saline 50units in 5ml (Hepsal) as prescribed by the doctor/non-medical prescriber.

3.10 Care of Wounds at Exit Site

When the wound has stopped oozing, a semi-permeable transparent dressing should be applied and changed every 7 days until line removal (Appendix 6), taking care not to dislodge the PICC line (appendix 3) (RCN 2010, Pratt et al. 2007, INS 2000). The aim of the transparent dressing is to maintain daily visual inspection RCN 2005) and prevent the introduction of organisms to the exit site.

Each time the dressing is changed; the exit site should be cleaned with Chlorhexidine 2% and 70% alcohol and allowed to air dry (Pratt et al. 2007, Wilson 2001).

For patients in hospital, the PICC line exit site must be observed on a daily basis for redness, swelling, soreness or exudate as localised infection may occur and subsequently track up the PICC line. If this is observed a swab should be taken from the site and sent to microbiology for culture and sensitivity. All observations must be recorded within the patient’s records (RCN 2010).

When patients are discharged from hospital, written and verbal information must be



given covering the signs and symptoms to observe for, and if appropriate they and/or their carers should be taught any techniques they may need to use to prevent infection and safely manage their device and a contact telephone number for the appropriate clinical area as necessary. (Pratt et al 2007)

Patients may take a shower, but it is not advised to immerse the PICC line in bath water, or to swim. This will reduce the risk of introducing organisms.

3.11 Occlusion of a PICC

Please refer to Appendices G and H for The Management of an Occluded Peripherally Inserted Central Venous Access Device (PICC Line).

3.12 Removal of a PICC Please refer to Appendix I

4.0 Consultation and Communication Process The consultation process involves dissemination of draft documents for comment to: the Arden Cancer Network Drugs and Therapeutics Committee, consultants haematologists, oncologists and haematology/oncology specialist nurses, ward managers and pharmacists at George Eliot Hospital, South Warwickshire NHS Foundation Trust, University Hospitals Coventry and Warwickshire and Worcestershire Acute Hospitals NHS Trust. 5.0 Equality Impact Assessment See Appendix J. 6.0 Review and Revision Arrangements including Version Control The Chair of the Arden Cancer Network Chemotherapy Group will nominate an individual to undertake a review of the guidance 3 months prior to the revision date. 7.0 Dissemination and Implementation Once documents are ratified, notification will be sent by email to the lead chemotherapy clinician, nurse and pharmacist for each Trust. It will be their responsibility to disseminate and implement the protocol locally. The final version of documents will be placed on the Arden Cancer Network intranet and each individual Trust’s intranet via a designated lead for each Trust. Hard copies will not be circulated. It will be the responsibility of departmental managers to remove outdated copies and to ensure staff are aware of the new version. It is the responsibility of departmental managers to implement any identified training or support.



8.0 References British Committee for Standards in Haematology (2003) Guidelines for the use of platelet transfusions British Journal of Haematology 122, 10-23. Carlson, K., Perdue, M. B. & Hankins, J. (2001) Infection Control, In Infusion Therapy in Clinical Practice. 2nd ed. Pennyslvannia:WB Saunders, Chapter 8, 126 – 140 (III) Department of Health (2009) Reference Guide to consent to examination or treatment. 2nd Edition. Department of Health (2007) Saving Lives: reducing infection, delivering clean and safe care Department of Health (2006) The Health Act – Code of Practice for the Prevention and Control of Health Care Associated Infections Department of Health (2001) Guidelines for preventing infection associated with insertion and maintenance of central vascular catheters Journal of Hospital Infection 47-supplement s47-67. Dougherty, L & & Lister, S (eds) (2004) The Royal Marsden Hospital Manual of clinical nursing procedures 6th. Ed. Oxford:Blackwell Publishing, Chapter 44. (III). Dougherty, L and Watson J (2008). ‘Vascular access devices’, in Dougherty L and Lister (editors) The Royal Marsden Hospital Manual of clinical Nursing Procedures (7th Edition), Oxford:Blackwell Publishing, Chapter 44. (III) Eliott TSJ, Tebbs SE (1998) Prevention of central venous catheter related infections Journal of Hospital Infection 40, 193-201. Gabriel J (1999) Long term central venous assess In: Dougherty L, Lamb J Intravenous Therapy in Nursing Practice Chapter 11 Edinburgh, Churchill Livingstone. Gabriel, J (2005) Vascular Access :indications and implications for patient care. Nursing Standard. Vol 19. No. 26. Pp45 – 52. Hart S (1999) Infection control in IV therapy In: Dougherty L, Lamb J Intravenous Therapy in Nursing Practice Chapter 4 Edinburgh, Churchill Livingstone. Hart S (2008b) ‘Infection control in Intravenous Therapy’ in Dougherty L and Lamb J (editors) Intravenous Therapy in Nursing Practice (2nd Edition), Oxford:Blackwell Science, (III).



Intravenous Nurses Society (2000) Standards for Infusion Therapy Cambridge, MA..INS, Beckton and Dickinson. Keenlyside (1992) Every little detail counts, Infection control in IV therapy. Professional Nurse. Vol. 7. No 4. pp 226 - 232. London Standing Conference (2002) Standards of care: External central venous catheters in adults London, LSC.

Mallett, J & Dougherty L (2000) Manual of Clinical Nursing Procedures. The Royal Marsden Hospital. 5th Edition. Blackwell Science, Oxford. National Institute of Clinical Excellence (2003) Infection Control: Prevention of health care associated infection in primary and community care (Clinical Guidelines 2) London, NICE. Nursing and Midwifery Council (2009) Guidelines for Records & Record Keeping. NMC: London. Nursing and Midwifery Council (2008) The Code of Professional Conduct: Standards for Conduct, Performance & Ethics. NMC:London. Pratt, R. J., Pellowe, C, M., Wilson, J A., Loveday, H. P., Harper, P. J., Jones, S. R. L. J., McDougall, C. & Wilcox, M. H. (2007) Epic 2. National evidence-based guidelines for preventing healthcare associated infections in NHS hospitals in England. Journal of Hospital Infection 65S, S1 – S64.. Perucca, R. (2001) Obtaining vascular access. In infusion therapy in clinical practice. 2nd. Ed. Pennsylvannia:WBSaunders, Chapter 20, 338 – 397. Philpot, P & Griffiths, V (2003) The Peripherally Inserted Central Catheter. Nursing Standard. Vol. 17, No. 44. Pp 39 – 46. Royal College of Nursing (2010) Standards for Infusion Therapy. 3rd Edition. RCN, London. Royal College of Nursing (1996) Guidelines on skin tunnelled catheters. 2nd edition. RCN. London. Saving Lives: Reducing infection, delivering clean & safe care. (2007) Central Venous Catheter Care Bundle. Department of Health. Todd J (1998) Peripherally Inserted Central Venous catheters (PICC) Professional Nurse 13 (5).



Vesley, T (2003) Central venous catheter tip position: a continuing controversy. Journal of Vascular Interventional Radiology. Vol. 8, No. 4. Pp 527 – 534. Wickham, R et al. (1992) Long Term CV’s:issues for care. Seminars in Oncology Nursing, Vol. 8. No.2 Pp 133-147. Wilson J (2001) Preventing Infection Associated with IV Therapy Infection Control in Clinical Practice (2nd Edition) London, Balliere Tindall.



9.0 Document Circulation

Name Title Trust Dates Circulated

Dr Jag Gandla Lead Chemotherapy Clinician

George Eliot Hospitals NHS Trust

6/2/2013

Melanine Bowling Lead Chemotherapy Nurse

6/2/2013

Melanie Taylor* Lead Chemotherapy Pharmacist

6/2/2013

Stephanie Cooke Lead Chemotherapy Pharmacist

Worcestershire Acute Hospitals NHS Trust

6/2/2013

Fay Lanham Lead Chemotherapy Nurse

6/2/2013

Sue Sharpe Chemotherapy Project Manager

6/2/2013

Ann Sullivan Cancer services Manager

6/2/2013

Dr Anton Borg Lead Chemotherapy Clinician

South Warwickshire NHS Foundation Trust

6/2/2013

Carole Connor* Nurse Consultant 6/2/2013

Nicola Evans Lead Chemotherapy Pharmacist

6/2/2013

Dr Lydia Fresco Lead Chemotherapy Clinician

University Hospitals Coventry and Warwickshire NHS Trust

6/2/2013

Dr Beth Harrison** Chair of the Haematology Network Site Specific Group

6/2/2013

Dr Clive Irwin Chair of Arden Cancer Network Chemotherapy Group

6/2/2013

Sam Neale* Lead Cancer Nurse 6/2/2013

Rebecca Aaron Chemotherapy Pharmacist

6/2/2013

Stephanie Connell***

Service Improvement Facilitator

Arden Cancer Network

6/2/2013

*Responsible for circulating to relevant staff within their Trust including clinical nurse specialists, oncologists and ward managers. **Responsible for circulating to Haematology Network Site Specific Group Members ***Responsible for circulating to Network Chemotherapy Cross Cutting Group



Appendix A

Procedure for the Insertion of Peripherally Inserted Central Catheters (PICC)

Equipment Required PICC line (dependant on supplier) Trolley prepared for aseptic technique as per Trust Guidelines Sharps bin Topical local anaesthetic Sterile gown Sterile large dressing towels/drapes Tourniquet Chlorhexidine 2% in 70% alcohol (Chloraprep) Powder free sterile gloves x 2 pairs Basic dressing pack (to include non-woven sterile gauze & gallipot) 50 ml infusion bag of 0.9% sodium chloride

heparinised saline 50units in 5ml (Hepsal) 3 x 10ml syringes Semi-permeable transparent dressing (i.e.IV 3000/tegaderm) Needle-less cap 2 x absorbent sheets Sterile steristrips +/- Statlock™ device Tape measure Sterile scissors Large Yellow Clinical Waste Bag

Procedure

Action Rationale

1. Perform effective decontamination of hands as per Trust Policy.

To minimise the risk of infection.

2. Assess the patient for suitable vein access and suitability of patient.

To ensure that this is the most appropriate device for the patient and to identify any possible contraindications of PICC placement.

3. Explain and discuss procedure to patient. Assess patients’ level of anxiety and give appropriate reassurance. Ensure consent has been sought.

To help relieve patients and anxiety and to ensure that the patient understands the procedure and gives his/her valid written consent.





5. Apply tourniquet and assess venous access, assessing both extremities, and locate veins by sight and palpation.

To ensure that the patient has adequate venous access and to select the vein for catheterisation.

6. Apply local anaesthetic cream to chosen venepuncture site and leave for allotted time.

To minimise the pain of insertion.


To minimize the risk of infection.

8. When the anaesthetic cream has been on for the desired time, position the patient comfortable on the bed and remove the cream.

To ensure the comfort of the patient.

9. Extend the patients arm 90° to their body and measure the distance from the insertion site to the head of the humorous across to the sternoclavicular junction. Note this measurement.

To enable selection of the most suitable catheter length and to establish how far to advance the catheter in order for the tip to be located in the correct position i.e. the Superior Vena Cava (SVC).



11. Check all equipment is intact & in date. Place all equipment required on the bottom shelf of a clean & disinfected trolley and place at the side of the patient’s bed/chair.

To reduce the risk of cross-infection.


To minimize the risk of infection.

13. Open insertion pack and create sterile field.

To minimise contamination of sterile field.

14. Put on sterile gown.

To minimise contamination of sterile field.

15. The assistant will position an absorbent sheet under the patients arm and loosely apply the tourniquet.

To protect the bedding.



16. Put on powder free sterile gloves and clean 10 – 15cms around the intended insertion site in concentric circles with Chlorhexidine 2% and Alcohol 70% (Chloraprep Sponge). Clean in a circular motion working outwards using a fresh swab each time. Repeat at least 3 times and allow to air-dry.

To remove skin flora and minimize infection risk.

17. Place sterile drape under patients arm and fenestrated drape over the top.

To create a sterile field.

18. Change gloves and arrange sterile supplies. Using a 50 ml infusion bag, draw up 0.9% sodium chloride in 2 x 10 ml syringes.

To help maintain sterile environment.

19. Dependent upon type of line used, trim the catheter to the required length and then prime with 1 x 10 ml syringe containing 0.9% sodium chloride. Using the rest of the infusion bag, if necessary soak the catheter in 0.9% sodium chloride.

To keep catheter moist and lubricated. Removes air from the PICC and checks catheter integrity.

20. Assistant to tighten tourniquet.

To aid venous distension.

21. Palpate the vein and perform venepuncture using appropriate introducer as per manufacturer’s instructions. Puncture the skin at a 15° - 30° angle. Advance 05. -1 cm once flashback is seen.

To gain venous access.

22. Release tourniquet.

To release pressure within the vein.

23. Remove the stylet leaving the introducer in-situ placing your thumb over the end of the introducer.

To reduce blood loss.

24. Hold the catheter 1cm from the tip and insert gently into the introducer.

To minimise collapse of the vein.

25. Instruct patient to turn their head towards you, with their ear flat on the pillow, and then bring the top of their head towards you so that their chin is on their shoulder.

To prevent the catheter entering the jugular vein and ensure the catheter advances down the SVC.



26. Gently advance the catheter to the pre-measured length.

If any difficulty e.g. the catheter will not thread: a. Reposition the arm. b. Inject 0.9% sodium chloride into the catheter whilst advancing it. DO NOT USE EXCESSIVE FORCE.

27. Aspirate for blood return.

To check patency of device.

28. Apply gently pressure on catheter and remove the guide wire slowly.

Removing the guide wire fast may damage the catheter.

29. Remove the introducer over the catheter.

30. Secure the catheter in place using the fixation method of choice, usually sterile steri-strips and/or a sterile Statlock™ device.

To ensure that the catheter does not move and prevent damage to the catheter.

31. Dependent upon type of line used, trim the catheter to the required length and assemble the catheter hub.

32. Attempt to aspirate blood from the catheter and flush with 0.9% sodium chloride (using a turbulent push – pause technique).

Ensure continued blood return with catheter hub attached.

33. Attach a needle-less cap.

34. Place non-woven gauze swab over the insertion site and cover with a semi-permeable transparent occlusive dressing.

Non-woven gauze is used for the first dressing only as there will be a small amount of oozing of blood initially from the venepuncture site.

35. Remove gloves and apron and fold up the sterile field, place it in the yellow clinical waste bag and seal it before moving the trolley. Dispose of waste in appropriate containers.

To prevent environmental contamination. Dispose of sharps and clinical waste appropriately to maintain a safe environment for patients and colleagues.

36. Decontaminate hands as per Trust Policy.


37. Confirm tip position by chest x-ray. To ensure that the tip is located in the lower third of the superior vena cava.



38. Document the procedure, to include:

Type and length of PICC line.

Vein used for venepuncture and umber of venepuncture attempts.

Gauge of cannula used.

Blood aspiration and tip confirmation.

Any complications.

How line was secured.

Patient education & follow-up care (NMC 2009).

To ensure adequate record and to meet legal/NMC requirements. To ensure continued care of device and patient.



Appendix B

Procedure for Withdrawing a Peripherally Inserted Central Catheter (PICC) Note: The chest x-ray must always be reviewed by a doctor prior to using the PICC line on the first occasion. If the chest x-ray indicates that the line is not in the superior vena cava, then the position of the line must be manipulated. Equipment Required Trolley prepared for Aseptic Technique as per Trust Guidelines Chlorhexidine 2% & Alcohol 70% (Chloraprep wand/sponge) 1 x pair powder free sterile gloves Procedure for Withdrawing of a Peripherally Inserted Central Catheter by a Measured Length

Action Rationale

1. Explain & discuss the procedure with the patient.

To ensure that the patient understands the procedure and gives his/her valid consent.



3. Prepare patient’s position using pillow to support arm of PICC line.

To ensure comfort of patient and that his/her arm is well supported during procedure.





6. Decontaminate hands as per Trust Policy. Put on an apron.


7. Open the outer cover of the sterile dressing pack and slide contents onto the top shelf of the trolley.

8. Open the sterile field using the corners of the paper. Open the other sterile packs, tipping their contents onto the centre of the sterile field. Break Chloraprep sponge/wand.

To reduce the risk of contamination of contents.



9. Attach yellow clinical waste bag to the side of the trolley below the level of the top shelf.

So that contaminated material is below the level of the sterile field.


Hands may have become contaminated by handling the outer packs etc.

11. Loosen the old dressing gently, remove and discard into yellow clinical waste bag.

12. Put on sterile gloves.

To minimise the risk of introducing infection.

13. Clean the wound with Chlorhexidine 2% and Alcohol 70% (Chloraprep wand/sponge), working from the inside to the outside of the area and dealing with the cleanest parts of the wound first. Allow the area to air-dry.

To minimise the risk of infection spreading from a ‘dirty’ to a ‘clean’ area. To enable disinfection process to be completed.

14. Gently pull the PICC line outwards until the desired length has been reached. .

To ensure that the catheter is lies in the correct position.

15. A repeat Chest x-ray may be required dependant upon the length of line withdrawn. This should be discussed with the medical team.

To ensure that the catheter is lies in the correct position.

16. Re-dress PICC line as per Appendix F.

To minimise the risk of introducing infection and to ensure that the PICC line is dressed as per policy.


To prevent environmental contamination.





Appendix C

Procedure for Taking Blood Samples from a Peripherally Inserted Central Catheter (PICC) Note:

Care should be taken when obtaining blood samples from a central venous catheter as inaccurate laboratory results may be reported especially coagulation values (RCN 2005).

This procedure may only be undertaken by staff competent at intravenous drug administration and who have received additional training in central venous access management.

Equipment Required Trolley prepared for aseptic technique as per Trust Guidelines Sharps bin 10mls 0.9% sodium chloride

heparinised saline 50units in 5ml (Hepsal) 2 x individual sterile 2% Chlorhexidine and 70% alcohol impregnated wipes 1 x pair powder free sterile gloves Basic dressing pack (to include non-woven sterile gauze & gallipot) 4 x 10 ml syringes Appropriate blood sample bottles Accurately completed investigation form Sterile needle-less cap Procedure

Action Rationale

1. Explain and discuss the procedure with the patient.















8. Open the sterile field using the corners of the paper. Open the other sterile packs, tipping their contents onto the centre of the sterile field.






11. Put on sterile gloves. To minimise the risk of introducing infection, and contamination where there is a potential of spillage of patient’s blood.

12. Grasp catheter end with a piece of non-woven sterile swabs and using a Chlorhexidine 2% & 70% alcohol wipe, clean the needless cap and allow to air dry.

To minimise the risk of contamination at the connections.

13. Using 10ml syringe draw up 10ml of 0.9% sodium chloride.

Any syringe size smaller than 10ml will risk the PICC becoming damaged or ruptured.

14. Using a 10ml syringe draw up 5ml of heparinised saline


15. Using a 10ml syringe, attach to the end of the PICC line and withdraw 5mls of blood. Discard into sharps bin.

To remove ‘dead space’ from the line which may contain organisms, clot and debris which are likely to cause inaccuracies in blood tests.

16. Attach a vacutainer barrel and adapter, unclamp line and attach appropriate blood bottles, allow to fill to correct amount of blood. (vacuum method).

To obtain the correct blood samples using a needle-less system.

17. Attach the syringe containing 0.9% sodium chloride to the end of the needle-less cap and flush into the PICC line using a push-pause method (inject 1ml at a time). Inject the contents of the syringe.

To create a turbulent flush to ensure removal of all blood in the catheter and prevent occlusion.



18. Attach the syringe containing heparinised saline to the end of the needle-less and flush into the PICC line, whilst injecting the last 0.5ml – 1ml maintain pressure on the plunger and remove the syringe from the line.

To maintain positive pressure and prevent back-flow of blood into the catheter and possible clot formation.

19. Cover catheter hub with sterile gauze and ensure it is secured with a semi-permeable occlusive dressing.

To ensure catheter hub is secured and will not cause any friction/trauma to the skin.





22. Ensure that blood samples have been placed in the correct containers and agitated as necessary to prevent clotting. Label them with patient’s name, hospital number, date of sample, location and send them to the laboratory with the appropriate forms.

To make certain that the specimens are correctly presented and identified, and are delivered to the laboratory, enabling the requested tests to be performed and the results returned to the correct patient’s records.



24. Document procedure in patient’s notes, including any complications noted and treatment implemented.

To ensure adequate records and enable continued care of device and patient (NMC 2009).



Appendix D

Procedure for Maintaining Patency (Flushing) of a Peripherally Inserted Central Catheter (PICC) Note:

This procedure must be performed after each use to prevent the mixing of incompatible medications and/or solutions, or every 7 days to promote and maintain patency.


Equipment Required Trolley prepared for aseptic technique as per Trust Guidelines Sharps bin 10mls 0.9% sodium chloride

heparinised saline 50units in 5ml (Hepsal) A sterile needle-less cap 2 x individual sterile 2% Chlorhexidine and 70% alcohol impregnated wipes 1 x pair powder free sterile gloves Basic dressing pack (to include non-woven sterile gauze & gallipot) 4 x 10 ml syringes Procedure

Action Rationale







4. Decontaminate his/her hands as per Trust Policy. Put on an apron.






6. Decontaminate hands as per Trust Policy and puts on an apron.










12. Grasp catheter end with a piece of non-woven sterile swab and remove cap using another piece of gauze. Using a Chlorhexidine 2% and 70% alcohol impregnated swab/wipe clean the catheter hub and allow to air dry.


13. Attach new sterile needle-less cap and swab with Chlorhexidine 2% and 70% alcohol impregnated swab/wipe. Allow to air dry.


14. Using 10ml syringe draw up 10mls of 0.9% sodium chloride.


15. Using a 10ml syringe draw up 5ml of heparinised saline.



To remove ‘dead space’ from the line which may contain organisms, clot and debris which are likely to cause inaccuracies in blood tests.

17. Attach the syringe containing 0.9% sodium chloride to the end of the needless cap and flush into the PICC line using a push-pause method (inject 1ml at a time). Inject the contents of the syringe.




18. Attach the syringe containing heparinised saline to the end of the needless cap and flush into the PICC line, whilst injecting the last 0.5–1ml maintain pressure on the plunger and remove the syringe from the line.

To maintain positive pressure and prevent back-flow of blood into the catheter, and possible clot formation.

19. Cover catheter hub with sterile non woven swab and ensure it is secured with a semi-permeable occlusive dressing (such as IV 3000).










Appendix E

Procedure for Administration of Intravenous Drugs via a Peripherally Inserted Central Catheter (PICC) Note: This procedure may only be undertaken by staff competent at intravenous drug administration and who have received additional training in central venous access management. Equipment Required Trolley prepared for aseptic technique as per Trust Guidelines Sharps bin 10mls 0.9% sodium chloride A sterile needle-less cap 2 x individual sterile Chlorhexidine 2% & 70% Alcohol impregnated wipes 1 x pair powder free sterile gloves Basic dressing pack (to include non-woven sterile gauze & gallipot) 2 x 10 ml syringes Intravenous Administration set Infusion bag of a compatible intravenous solution Minimum of 10mls Sodium chloride heparinised saline 50units in 5ml (Hepsal) Intravenous drugs required 21 gauge needles Procedure

Action Rationale


















9. Prime the intravenous infusion set with compatible intravenous solution.

To prevent air embolism.






13. Grasp catheter end with a piece of non-woven sterile gauze and remove cap using another piece of gauze. Using a Chlorhexidine 2% and 70% alcohol impregnated swab/wipe clean the catheter hub or clean the needle-less cap with a 2% Chlorhexidine and 70% alcohol impregnated swab/wipe and allow to dry.



To remove any organisms, debris and heparin that may be in the line.



16. Attach the syringe containing 0.9% sodium chloride to the end of the needle-less cap and flush into the PICC line using a push-pause method (inject 1ml at a time). Inject the contents of the syringe.

To create a turbulent flow in order to flush the catheter thoroughly.



17. If using an intravenous infusion, connect the intravenous infusion set to the PICC line at the needle-less cap/ catheter hub and secure with tape.

18. Commence compatible intravenous infusion.

To check patency of PICC line. To ensure that there is an adequate flush between drugs administered.

19. Administer intravenous drugs ensuring that a minimum of 20mls of compatible infusion fluid is used between each drug.

To ensure safe administration of intravenous drugs.

20. Stop infusion of 0.9% sodium chloride ensuring adequate flush post administration of intravenous drugs.

21. Remove gloves and dispose of in appropriate container.



23. Once drug administration is complete; if short bolus drug given, it is only necessary to change sterile gloves prior to flushing off. If longer bolus/infusional drugs administered set up a new sterile field, opening the dressing pack using the corners of the paper, open the other sterile packs, tipping their contents onto the centre of the sterile field.


24. Using a 10ml syringe draw up 5ml of heparinised saline

Any syringe size smaller than 10ml will risk the becoming damaged or ruptured.

25. Attach if necessary a new sterile needle-less cap. Attach the syringe containing heparinised saline to the end of the needless cap and flush into the PICC line, whilst injecting the last 0.5–1ml maintain pressure on the plunger and remove the syringe from the line.


26. Cover catheter hub with non-woven sterile gauze and ensure it is secured with a semi-permeable transparent dressing.








29. Document procedure in patient’s notes, including drugs administered, rate of administration, any complications noted and treatment implemented.




Appendix F

Procedure for Dressing a Peripherally Inserted Central Catheter (PICC) Note:

Semi-permeable transparent dressings should be changed every 7 days, unless there are signs of exudate or infection or as per manufacturer’s guidelines.


Equipment Required Trolley prepared for aseptic technique as per Trust Guidelines 1 x individual package of 2% Chlorhexidine and 70% alcohol impregnated wand 1 x pair powder free sterile gloves Basic dressing pack (to include non-woven sterile gauze & gallipot) Semi-permeable transparent dressing Sterile steristrips +/- Statlock™ device Procedure

Action Rationale

1. Explain & discuss the procedure with the patient.


2. Decontaminates his/her hands as per Trust Policy. Put on an apron.


3. Assess PICC line entry site for signs of redness, inflammation, tenderness or exudate.

To identify signs of infection, swabbing the area for culture and sensitivity may be necessary.












9. Open the sterile field using the corners of the paper. Open the other sterile packs, tipping their contents onto the centre of the sterile field. Break Chloraprep wand.







13. If the site is red or discharging take a swab for bacteriological investigation.

For identification of pathogens. To predict colonisation of the site.

14. Ensure that swab has been placed in the correct container, label with patient’s name, hospital number, date of sample, location and send to the laboratory with the appropriate forms.

To make certain that the specimens are correctly presented and identified are delivered to the laboratory, enabling the requested tests to be performed and the results returned to the correct patient’s records.



16. Put on sterile gloves.


17. Clean the wound with individual package of 2% Chlorhexidine and 70% alcohol impregnated swabs/wipes working from the inside to the outside of the area and dealing with the cleanest parts of the wound first. Allow the area to air-dry.

To minimise the risk of infection spreading from a ‘dirty’ to a ‘clean’ area. To enable disinfection process to be completed.

18. Apply sterile steri-strips or a sterile Statlock™device, followed by a semi-permeable transparent dressing.

To ensure stability of device. and protection of the site.

19. Cover catheter hub with non-woven sterile gauze and ensure it is secured with a semi-permeable occlusive dressing.




Appendix G

Procedure for Unblocking an Occluded Peripherally Inserted Central Catheter (PICC) Note:

Catheters can become occluded or blocked for a number of reasons, e.g. not being flushed adequately or using the incorrect flushing technique, the infusion being switched off or running too slowly, precipitation formation due to inadequate flushing between solutions/drugs.

Excessive force must never be used to unblock a PICC line, clearance of an occlusion is best performed using a negative pressure approach. The establishment of negative pressure within a PICC line means creating a vacuum by aspiration of the air or ‘dead space’ within it. (Moureau et al. 1999). Thrombolytic agents specifically indicated for dissolving clots may be administered and have to be prescribed.


Equipment Required Trolley prepared for aseptic technique as per Trust Guidelines Sharps bin 10mls 0.9% sodium chloride heparinised saline 50units in 5ml (Hepsal) A sterile needle-less cap 2 x individual sterile 2% Chlorhexidine and 70% alcohol impregnated wipes 1 x pair powder free sterile gloves Basic dressing pack (to include sterile gauze & gallipot) 4 x 10 ml syringes Prescribed thrombolytic agent (Urokinase 5000iu in 2mls) 3 way tap

Procedure

Action Rationale



2. Decontaminate hands as per Trust Policy and put on an apron.



To ensure comfort of patient and the patient’s arm is well supported during procedure.

4. Decontaminates his/her hands as per Trust Policy.
















12. Grasp catheter end with a piece of non-woven sterile swab and remove needle-less cap using another piece of gauze. Using a Chlorhexidine 2% and 70% alcohol impregnated wipe, clean the catheter hub and allow to air dry.


13. Using a 10ml syringe attempt to aspirate 5mls blood from the line.



15. If unsuccessful attempt to flush line with 0.9% sodium chloride using a 10ml syringe.


16. If there is resistance to instilling 0.9% sodium chloride into lumen, attempt gently to instil the 0.9% sodium chloride using a ‘to and fro’ motion (push-pull) over a few minutes.

To attempt to clear the catheter.



17. If nothing can be aspirated, attach a three way tap and to this add an empty 10ml syringe and a 10 ml syringe containing

heparinised saline 50units in 5ml (Hepsal).

To commence the negative pressure technique.

18. Attempt to unblock catheter using the negative pressure technique.

This enables the solution to be drawn into catheter without creating any pressure which could result in catheter rupture.

19. UNBLOCKING AN OCCLUDED CATHETER:

Turn tap to close off pre-filled syringe.

Open tap to empty syringe and aspirate to create a negative pressure.

Turn tap to close off empty syringe.

Open tap to prefilled syringe, the medication will automatically be aspirated into the catheter. Repeat as necessary (Mallett & Dougherty 2000).

20. If still unable to aspirate, then determine the cause of the occlusion

Blood.

Precipitation.

To break down fibrin.

To break down drug precipitation or fat emulsion.

21. Draw up prescribed urokinase.

To prepare appropriate equipment.

22. Clean gloved hands with bactericidal alcohol hand rub.


23. Attempt to unblock catheter as No. 19 using Urokinase 5000u in 2mls (RCN 2005).

To prevent catheter rupture.

24. Cap off catheter and leave for allotted time: one hour or maximum 4 hours. Ensure PICC line is labelled ‘Urokinase in situ’.

To allow the drug to destroy fibrin.

25. Decontaminate hands with as per Trust Policy.


26. Set up sterile field as previously.




27. Put on sterile powder free gloves.


28. Grasp end of catheter with a piece of 29. non-woven sterile gauze and remove

needle-less cap using another piece of gauze. Using a Chlorhexidine 2% and 70% alcohol impregnated wipe, clean the catheter hub and allow to air dry.


30. Attach an empty 10ml syringe to catheter and attempt to aspirate any clots and solution.

To unblock catheter and ensure no clots are administered into the patient.

31. If blood returns, withdraw at least 10mls and discard.

To ensure that no urokinase or clots are flushed into the catheter.

32. Attach the syringe containing 0.9% sodium chloride to the end of the needle-less cap and flush into the PICC line using a push- pause method (inject 1ml at a time). Inject the contents of the syringe.


33. Attach the syringe containing heparinised saline to the end of the needle-less cap and flush into the PICC line, whilst injecting the last 0.5ml–1ml maintain pressure on the plunger and remove the syringe from the line.


34. Cover catheter to hub with non-woven sterile gauze and ensure it is secured with a semi-permeable transparent dressing.








38. Note: If still unable to aspirate, it will be necessary to remove the catheter.

If occlusion cannot be removed the catheter is no longer patent.



Appendix H (RCN 2010)

Procedure for The Management of Persistent Withdrawal Occlusion in a PICC Line

Note: Persistent withdrawal occlusion (PWO) is defined as fluids that can be infused freely by gravity but blood cannot be withdrawn from the catheter (London Standing Committee 2001).

BLOOD RETURN IS

ABSENT

Ask patient to cough, deep breathe, change position, stand up or lie with foot of the bed tipped up. Ascertain possible

cause of PWO. Ensure line is not kinked.

Blood return obtained – use central venous

catheter as usual.

BLOOD RETURN IS STILL ABSENT

Flush central venous catheter with 0.9% sodium

chloride in 10ml using a brisk ‘push pause’

technique. Check for flashback of blood.

The following steps should initially be done on admission or prior to drug administration and documented in the nursing care plan so that all staff are aware that patency has been verified.

STEP 1

Administer a 250ml normal saline ‘challenge’ via an infusion pump over 15 minutes to test for patency – the infusion will probably not resolve the lack of blood return (unless the patient has a high sodium or is on restricted fluid – go to step 2) If there have been no problems, therapy can be administered as normal. If the patient experiences ANY discomfort or

there is any unexplained problems then stop and seek medical advice. It may be necessary to verify tip location by chest x-ray.

STEP 2 Instil urokinase 5000 IU in 2mls and leave for a minimum of 60 minutes. After this time withdraw urokinase and assess

the catheter again. Repeat as necessary and leave for at least 4 hours. If blood return is still absent it may be necessary to verify tip location by chest x-ray.

BLOOD RETURN IS

STILL ABSENT

Patient is to receive highly irritant/vesicant drugs or

chemotherapy

YES

NO

Proceed if happy to do so as long as there are no

other complications or pain



Appendix I

Procedure for the Removal of a Peripherally Inserted Central Catheter (PICC) Note:

The removal of PICC lines must only be undertaken by an appropriately trained practitioner. Equipment Required Trolley prepared for aseptic technique as per Trust Guidelines 1 x pair powder free sterile gloves Basic dressing pack (to include non-woven sterile gauze & gallipot) 2 x individual sterile 2% Chlorhexidine and 70% alcohol impregnated wipes Semi-permeable transparent dressing Procedure

Action Rationale





3. Assess PICC line entry site for signs of redness, inflammation, tenderness or exudate.

To identify signs of infection. Swab of the area for culture and sensitivity may be necessary.


To ensure comfort of patient and the patient’s arm is well supported during procedure.










9. Open the sterile field using the corners of the paper. Open the other sterile packs, tipping their contents onto the centre of the sterile field. Pour lotion into gallipot.







13. Put on powder-free sterile gloves.


14. If the site is red or discharging take a swab for bacteriological investigation.

For identification of pathogens. To predict colonisation of the site.

15. Clean the wound with individual package of 2% Chlorhexidine and 70% alcohol impregnated swabs/wipes working from the inside to the outside of the area and dealing with the cleanest parts of the wound first. Allow the area to air-dry.

To minimise the risk of infection spread from ‘dirty’ to a ‘clean’ area. To enable disinfection process to be completed.

16. Gently pull the PICC line outwards until completely removed from exit site.

To remove the catheter.

17. Apply hand pressure over the exit site for 2–3 minutes and apply sterile dressing.

Minimise blood loss and risk of bruising.

18. Examine length and tip of PICC to ensure complete and send the tip off to microbiology for culture & sensitivity.

To ensure complete catheter removal.



20. Decontaminate hands as per Trust Policy To reduce the risk of cross-infection.



Appendix J - Equality Impact Assessment Tool

Yes/No Comments

1. Does the document/guidance affect one group less or more favourably than another on the basis of:

Race No

Ethnic origins (including gypsies and travellers)

No

Nationality No

Gender No

Culture No

Religion or belief No

Sexual orientation including lesbian, gay and bisexual people

No

Age No

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

2. Is there any evidence that some groups are affected differently?

No

3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable?

No

4. Is the impact of the document/guidance likely to be negative?

No

5. If so, can the impact be avoided? N/A

6. What alternative is there to achieving the document/guidance without the impact?

None

7. Can we reduce the impact by taking different action?

No



Appendix L - Plan for Dissemination of Procedural Documents

Title of document: Guidelines for the Insertion and Management of Peripherally Inserted Central Catheters (PICC) in Adult Haematology and Oncology Patients

Date finalized: Dissemination lead: Sam Neale – Lead Cancer Nurse, GEH NHS Trust

Previous document already being used?

Yes

If yes, in what format and where?

Second Version of Guidelines for the Insertion and Management of Peripherally Inserted Central Catheters (PICC) in Adult Haematology and Oncology Patients

Proposed action to retrieve out of date copies of the document:

Second Network Wide document across Haematology and Oncology. Chemotherapy lead nurse for each Trust to retrieve local documents

To be disseminated to: How will it be disseminated, who will do it and when?

Format (i.e. paper

or electronic)

Comments:

Stephanie Connell – Arden Cancer Network

To inform all areas that revised network wide electronic version available on Trusts intranet and Arden Cancer network site with 7 days of receipt

Electronic Sent by email

Sam Neale – Lead Cancer Nurse – George Eliot Hospitals NHS Trust

Carole Connor –Nurse Consultant, South Warwickshire NHS Foundation Trust

Lead Chemotherapy Nurse – University Hospitals Coventry and Warwickshire NHS Trust

Dissemination Record - to be used once document is approved

Date put on register / library of procedural documents:

Date due to be reviewed:

Disseminated to: (either directly or via

meetings, etc.)

Format (i.e. paper or

electronic)

Date Disseminated:

No. of Copies Sent:

Contact Details / Comments:

Directly Electronic One Sam Neale – Lead Cancer Nurse – GEH NHS Trust