(CVC) Management Guidance - the Royal Cornwall Hospitals Trust ...

Peninsula Community Health
Central Venous Catheter (CVC) Management
Guidance (Excludes Dialysis Catheter)
Title:
Guidelines for Central Venous Catheter
Management
Procedural Document Type:
Guidelines
Reference:
CG-MM-G02
CQC Outcome: Outcome 4 & Outcome 9
Version: Version 1
Approved by:
IV Training Meeting
Ratified by:
Clinical Quality and Safety Committee
Date ratified: 19 th June 2012
Freedom of Information:
This document can be released
Name of originator/author:
Andy Shaw
Name of responsible team:
Clinical Governance
Review Frequency:
3 Years or dependent on change in practice
Review Date: 19 th June 2015
Target Audience:
All Clinical Staff
Executive Signature (Hard Copy Only):

Contents
1 Introduction ........................................................................................................ 3
2 Definitions .......................................................................................................... 3
3 Duties................................................................................................................. 3
4 Central Venous Catheters.................................................................................. 5
5 Indications for a Central Venous Catheter.......................................................... 5
6 Staff Who Can Manage / Access CVC’s ............................................................ 6
7 Insertion of CVC’s .............................................................................................. 6
8 Care of Central Venous Catheters ..................................................................... 6
8.1 Dressings (i.e PICC & Hickman style) (refer to appendix 1)......................... 6
8.2 Flushing CVC Lines (Appendix 11 SOP 1, 2, 4)........................................... 7
8.3 Open and closed valve systems: ................................................................. 7
8.4 Locking......................................................................................................... 8
9 Blood Sampling from a Central Venous Catheter (SOP 3)................................. 8
10 CVC problems.................................................................................................... 8
10.1 Occlusions.................................................................................................. 8
11 Removing CVC’s................................................................................................ 9
11.1 Indications for Catheter Removal ............................................................... 9
11.2 PICC line removal ...................................................................................... 9
11.3 Documentation of line removal must include:........................................... 10
12 CVC Infections ................................................................................................. 10
12.1 Suspected Insertion Site Infections .......................................................... 10
12.2 Blood Cultures.......................................................................................... 10
13 Education ......................................................................................................... 10
13.1 Staff.......................................................................................................... 10
13.2 Patients .................................................................................................... 11
14 Risk Management Strategy Implementation..................................................... 11
14.1 Implementation & Dissemination ........................................................ 11
14.2 Training and Support .......................................................................... 11
14.3 Document Control & Archiving Arrangements .................................... 11
14.4 Equality Impact Assessment............................................................... 12
15 Process for Monitoring Effective Implementation ............................................. 12
16 Associated Documentation............................................................................... 12
17 References....................................................................................................... 12
Please Note the Intention of this Document
These guidelines have been developed to ensure that registered staff have correct and clear
guidance with regards to the care, maintenance and removal of these lines.
Review and Amendment Log
Version No Type of Change Date Description of change

1 Introduction
As central lines become more common place in the Cornish community it has been deemed
essential that registered staff have correct and clear guidance with the care, maintenance
and removal of these lines regardless from which hospital they originate. Cornwall is
serviced by three main District General Hospitals (DGH) and the central venous catheter
(CVC) policies/guidelines from each have been considered in the preparation of this
guideline. In addition to the existing DGH policies, guidance from the Royal Marsden Manual
for Clinical Nursing Procedure (2011) and EPIC2: National Evidence- Based Guidelines for
Preventing Healthcare-Associated Infections have been used to establish best practice. It is
applicable to all registered practitioners undertaking management of these lines.
2 Definitions
Central Vascular Catheter (CVC): Invasive catheter inserted into a large vessel ending at
the superior vena cava.
Flush: Method of clearing or keeping patent a CVC
Lock: The amount of solution that is to be kept in the length of the line in millitres (mLs) after
flushing.
Clamp: A device situated on the external part of a CVC to close the line.
Open system CVC: A CVC that has no internal non return valve system
Closed system CVC: A CVC that has an internal device (port) that stops flash back into the
line. These systems often lack the need and therefore a clamp.
MVTR: Moisture Vapour Transmission rate. Term applied to occlusive transparent dressings
to denote the amount of moisture that can move away from the wound/entry site reducing
bacterial build up.
CCAT: Central Catheter Assessment Tool used by Derriford Hospital (PHNT) to assess
central lines for possible infection (similar to VIP).
Clave: Proximal end catheter device to help maintain closed sterile system. Has septum and
luer attachment for accepting syringes.
Vacutainer: A device that allows a blood bottle to be inserted to obtain blood from
lines/needles.
VIP score: Visual Infusion Phlebitis score used to assess whether a CVC or peripheral
invasive line is causing phlebitis.
3 Duties
The Director of Nursing and Professional Practice is ultimately responsible for the
content of this policy and it’s implementation.
PCH Directors are responsible for the implementation of this policy across all clinical
services. The policy when ratified will be posted on the intranet.

Individual Matrons, Clinical Managers, Professional and Clinical Leads are responsible
for ensuring staff are working to the guidance of the policy and monitoring its
implementation.
Clinical staff are responsible for ensuring they work within the guidance of the policy.
Peninsula Community Health are responsible in partnership with the medical physics
teams to ensure that all intravenous pumps are appropriately serviced annually and an audit
trail is available.
Peninsula Community Health are responsible for providing and ensuring that all staff using
medical devices are appropriately trained (MDA 2006).
All staff have a responsibility to prevent and manage healthcare acquired infection as part
of The Health Act Code of Practice for the Prevention and Control of Health Care Associated
Infections (Department of Health, 2006).
All Healthcare Professionals have a duty of care to their patients. This is a legal and
professional requirement of state registration that cannot be delegated. It is the responsibility
of the healthcare professional to ensure any IV access or therapy (including delegation to
another Practitioner) is performed as per PCH policy and procedures.
Pharmacists are responsible for monitoring both the prescribing and the administration of
Medicine therapies and alerting prescribers and other health care professionals to potential
problems.
Responsibilities of Registered Nurses
All Registered Nursing Staff administering intravenous drugs must have current Nursing
and Midwifery Council registration.
Nurses are accountable for their own professional practice and must work within this
policy and respective professional codes and any associated legislation.
All Registered Nursing Staff are personally responsible and accountable to ensure they
receive training in the safe use and observation of any medical devices they need to use
(MDA2006).
Nurses who have undertaken the PCH training (or satisfy the criteria for employees
originating from outside the PCH). and competency may manage Central and midline
catheters
Nurses can administer IV medication to adult patients only, unless they have undertaken
additional training and assessment.
Cytotoxic IV drugs are NOT to be administered by nurses unless they have undertaken
additional training and assessment.
Controlled drugs must not be administered Intravenously by nursing staff in any
circumstance.
IV drugs can only be administered by a nurse if the procedure is within that individual’s
knowledge and scope of practice.
All administrations must comply with the Community Health Services Policy for the Safe
Ordering Prescribing and Administration of Drugs in Community Hospitals and Minor
Injury Units, (April 2010) and the NMC (2008) Standards for Medicines Management.
Healthcare Assistants who have completed appropriate PCH training and been assessed
as competent can undertake Venepuncture. Healthcare Assistants must not administer IV
medication or cannulate a patient. Healthcare Assistants are not authorised to manage any
aspect of Central or midline catheters
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Band 4 Practitioners who have completed PCH training and been assessed as competent
can undertake venepuncture and cannulate patients. They can administer the initial flush
when the cannula is inserted, if it has been prescribed and checked by a registered
healthcare professional, but are not authorised to administer any other flush or IV
medication. Band 4 practitioners are not authorised to manage any aspect of Central or
midline catheters
Responsibilities of the medical staff
Doctors must provide a clear, legal, complete and unambiguous prescription, in
accordance with Community Health Services Policy for the Safe Ordering Prescribing
and Administration of Drugs in Community Hospitals and Minor Injury Units, (April 2010),
to guide the person involved in IV administration.
Peninsula Community Health staff are not authorised to prescribe or administer
controlled drugs intravenously but may act as a second checker. A Medical
Practitioner may administer controlled drugs intravenously in an emergency.
It is recommended that complex IV drug calculations are checked by a second person
(either a medical practitioner or a registered nurse) before administration (NMC, 2008)
Nominated Community Health Services Dental Practitioners may prescribe and
administer IV Midazolam for ‘conscious sedation’, following General Dental Council
guidance. Two registered dental nurses must be in attendance, one of whom must hold a
post qualification certificate in conscious sedation (NEBDN).
NB: The use or continuation of the IV route is justified only where there is a clear benefit
to the patient. Therefore, reassessment every 48 hours and documentation of the
decision should be completed and alternative administration routes should be considered
if necessary.
Students
Students are not permitted to administer any Intravenous medication or fluids and as such
are not permitted to access CVC’s. They may act as a second checker for medication where
calculations are not required.
4 Central Venous Catheters
A central venous catheter is threaded into the central vasculature. A CVC tip will always be
in the superior vena cava (SVC) or right atrium (Dougherty & Lister, 2011). Due to the
location of the tip, a closed system is used and strict asepsis is required. Three way taps are
not to be used in a community setting and if present should be removed immediately and
replaced with a non return valve and reported on Datix Incident reporting system.
5 Indications for a Central Venous Catheter
In the case of poor peripheral access, a midline must be considered before a central venous
catheter. Indications for a central venous catheter include:
To provide long-term access (greater than 4 weeks) for repeated transfusions of
blood, blood products (as indicated by consultant)
Parenteral nutrition
Cytotoxic or antibiotic therapy or where a midline is clinically inappropriate.
To provide reliable access for:
Hydration or electrolyte maintenance
Administration of drugs harmful to peripheral veins, such as potassium
chloride
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Repeated specimen collection
6 Staff Who Can Manage / Access CVC’s
Staff managing CVC’s in the PCH must fulfil the following criteria:
Are a registered healthcare professional
Have successfully completed PCH Intravenous Drug (I.V.) therapy course and
fulfilled the PCH competency assessment
Must have completed further training in the management of central lines
Have been assessed as competent in the management of these devices
7 Insertion of CVC’s
A CVC line will only be inserted in an acute setting unless specific arrangements have been
made with the acute care team for insertion in a community hospital. In the case of the latter
X-ray facilities must be available on site. A detailed care plan must support the insertion for
care and maintenance of the device.
8 Care of Central Venous Catheters
8.1 Dressings (i.e PICC & Hickman style) (refer to appendix 1)
The central venous catheter (CVC) / central venous access device (CVAD) must
be carefully observed to assess if the dressing is intact and to detect any early
signs of infection e.g. redness and warmth.
No antimicrobial ointments should be used on the catheter site
ANTT with sterile gloves must be used for all CVC dressings and procedures (see
Appendix ).
A Chloraprep® applicator of 3mL Chlorhexidine 2% in Alcohol 70% must be used
to clean the skin area before new dressing is applied.
The dressing of choice is the Central Line I.V. 3000®. This dressing has a high
Moisture Vapour Transmission Rate (MVTR) which helps remove moisture build
up and therefore reducing the ideal environment for bacteria.
The site must be observed for erythema or inflammation and the Visual Infusion
Phlebitis (VIP) or Central Catheter Assessment Tool (CCAT) (Appendix 1-1/2)
score should be indicated in the care plan each time the device is accessed or at
minimum daily or as condition dictates. In the community an appropriate person to
monitor the site may be the patient or carer.
Peripherally Inserted Central Catheter’s (PICC) are not stitched in place and require
securing. Devices used for this range from the clear occlusive dressing and in
addition a grip lock below.
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Grip-Lok is a flexible low profile PICC and Midline catheter securement device specifically
designed for maximum patient comfort, compatible with most PICC and Midlines.
8.2 Flushing CVC Lines (Appendix 11 Standing Operating Procedures 1,
2, 4)
Before accessing the line a visual check of the site must be undertaken and the VIP/
CCAT score documented in patient care plan.
All lumens must be flushed with 10-20mL sterile Sodium Chloride 0.9% before and
following each drug administration and following blood sampling.
Heparin should not be used as an end lock unless otherwise indicated by the Acute
Trust and as a double precaution to catheter blockage.
Where there is directive in the care plan requiring Heparin a rationale must be
supplied with a full prescription of the exact amount of Hepsal/Heparin required in
strength and amount in mLs. Where Heparin lock is prescribed this should initially be
prescribed and supplied by the acute trust
Implanted Ports (Portacaths) are the only central lines where Heparin is regularly
prescribed from NDDH/RCHT/PHNT as a lock.
On occasions a needle can be left in situ, When the needle is taken out a Heparin
100iu/mL is used and when needle is left in 10iu/mL is used.
All Flushes to a CVC must be prescribed.
A 10mL (or larger) luer lock syringe must be used with a pulsated push-pause (startstop)
technique and maintain positive pressure on the syringe when closing the
clamp and before removing the syringe.
Maintaining a positive pressure is essential to stop clots forming in the tip of the
catheter.
Ensuring the clamp remains closed before attaching the luer lock syringe into the
septum of the clave will ensure a closed system is maintained. This will reduce the
risk of air emboli in the system.
8.3 Open and closed valve systems:
Some central lines have a non return valve in the system and it can be at either the
proximal or distal end of the catheter.
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In these cases where there is a valve there may be some lag when drawing back and
testing for patency, so be patient.
Some closed systems lack a clamp as it is not required. So therefore an open system
may require a Heparin lock which must be prescribed as above.
8.4 Locking
The lock is what is intentionally left in the line to keep it patent. Sometimes this is
done with Heparin. It is important to note that Heparin is never to be used to flush
the line and the amount of lock should only be that of the line in mLs. This amount
depends on line length and if indicated this should be in the care plan and prescribed
Always attempt to aspirate any Heparin lock before use of the line, discuss with
consultant whether Heparin can be flushed into patient when aspiration is not
possible. The rationale for Heparin use should come from a consultant who would
have considered the risk of Heparin Induced Thrombocytopenia (HIT).
A flush will clear the line. When using a saline flush only, this acts as the lock
providing the clamp is applied during the last 1-2mLs under positive pressure.
9 Blood Sampling from a Central Venous Catheter (SOP 3)
Blood collection procedure applies for all sampling and the PCH policy must be adhered to
whether peripheral or CVC. Sampling from a central line must only be performed when no
other access is available or appropriate.
This must only be undertaken by practitioners who have been assessed as competent to
undertake the procedure.
In adults, the Vacutainer system must be used using ANTT.
All infusions via the line to be used must be stopped for 15 minutes before sampling. The
first 5mLs of blood must be withdrawn (using blood bottle) and discarded (except for blood
cultures).
The adapter needle (blue) must be attached for Vacutainer use.
On completion flush with at least 10mL Sodium Chloride 0.9% (unless specified otherwise) is
required to keep the line patent using the previous technique. (Refer to SOP3 in this
document)
10 CVC problems
10.1 Occlusions
Occlusion rates within CVC’s are low, but it is still the most common non-infectious
complication. Signs of a catheter occlusion include:
Inability to flush
Inability to aspirate ‘lock’ or withdraw blood although ‘flushing’ may be possible
Sluggish or intermittent free flow of fluids
If the CVC is occluded try:
Un-kink the line
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Undo the clamp
Get patient to cough
Try to aspirate and clamp. Flush the line after unclamping
Get patient to move position
Use a push pull technique with the flush
Urokinase is not to be used in a home situation. In a community hospital discuss
use with the doctor and if indicated administer using method described in the
Royal Marsden Manual.
Occlusions can be described as either partial or complete; in either case it is important to
ascertain the cause of the occlusion before taking appropriate action. In situation where
there is a total blockage discuss with relevant doctor and consider removal.
11 Removing CVC’s
11.1 Indications for Catheter Removal
The catheter should only be removed in the following circumstances after Consultant
opinion has been sought:
Patient preference
Short term catheter
Suspicion of complicated infections e.g. Septic thrombosis, endocarditis,
osteomyelitis or possible metastatic seeding
Confirmed staphylococcus aureus infection
Confirmed fungal infection
11.2 PICC line removal
When instructed or a clinical need is assessed by a Consultant a registered
Practitioner who has been deemed competent can remove a PICC line in a
community hospital. Due to possible complications this is not to be done in a home
setting. This procedure is done using ANTT.
Determine the patients clotting status/INR
If possible lie patient down or position entry site so that it is lower than the heart
Using ANTT expose line and prepare sterile field
Measure line and compare to care plan
Clamp the line (avoids air emboli)
Using ANTT gently remove line using a steady and constant motion until line is
completely removed
Apply digital pressure to the site for approximately 2-5 minutes to stop bleeding
and air entry
Check length of line is the same length as when inserted by measuring
Apply sterile dressing and observe for further bleeding
If infection is suspected remove 5cm of tip using sterile scissors and send to
microbiology for investigation
If resistance is felt stop. Apply warm towel to arm and attempt after approx 20 mins. If
thrombus or a broken line is suspected stop, seek medical assistance. Patient will have to be
thrombolised before removal.
*Tunnelled lines / implanted ports require surgical removal at an appropriate location.
Multiple lumen lines in the Internal Jugular should not be in the community but are removed
using a Val Salva technique refer to Royal Marsden. Advice from Acute Trust should be
sought.
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11.3 Documentation of line removal must include:
Reason for removal
Length of catheter removed (which must be checked against insertion
information)
Confirm if the catheter tip has been sent for culture
Technique used
12 CVC Infections
Infection is one of the most frequently reported complications of CVC’s. If a catheter related
blood stream infection is suspected or confirmed, alternative vascular access should be
sought until the issue is resolved.
The following guidance represents current best practice however; practitioners should seek
guidance from appropriate medical staff, Infection prevention & control team, microbiology
team and pharmacist.
Practitioners need to audit their own practice as part of infection prevention measures by
completing a Central catheter form,
Each time a port is accessed there is a risk of infection. This guideline mandates ANTT
when accessing a CVC which will further reduce the risks of bacteraemia in lines.
The method of cleaning ports and hubs prior to access is the same as all vascular access
devices. A Chlorhexidine 2% and Alcohol 70% (PDI or Clinell® wipe is to be used.
For patients where there is an allergy/reaction likely to Chlorhexidine, a Povidine Iodine 10%
aqueous solution should be used.
12.1 Suspected Insertion Site Infections
A swab must be taken from the insertion site before commencing systemic antibiotic
therapy.
If a swab is taken the result must be followed up within 48 hours and discussed with
the Medical Management Team.
A daily assessment including VIP, Temperature, Pulse, Respirations and dressing
change to be initiated.
12.2 Blood Cultures
Where a catheter related blood stream infection is suspected a minimum of two blood
culture samples are required. The cultures must be taken using a closed system.
One set of cultures must be taken from the CVC (or a sample from each lumen) and
the other taken peripherally before commencing antibiotic therapy. This is a
procedure to be undertaken by medics only.
13 Education
13.1 Staff
All registered practitioners accessing CVC’s should be fully trained in intravenous
infusions, be deemed competent to PCH standards and have had additional teaching
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and local assessment by a registered healthcare practitioner who themselves have
experience in caring for CVC’s.
Staff should also have completed the PCH infection control and ANTT training and
be fully up to date with Anaphylaxis training.
Training for CVC management will be provided by the IV link trainers
Additional training may be required when accessing implanted ports and where an
opportunity arises to gain this from an acute setting prior to discharge the staff should
be encouraged to take the opportunity.
13.2 Patients
If patients/carers are deemed able to self manage the CVC they should be made fully
aware of the risks involved. They must be given advice and taught how to care for
the line safely during their hospital stay and following discharge.
The patient (and carer/other if appropriate) must be given advice verbally and this
should be supported by written information in a format they understand.
Contact details for 24 hour advice must be provided in case the patient has any
concerns regarding line care.
A full care plan/information pack must accompany the patient on discharge and the
Community Teams must be included in the discharge planning.
Dressing change must be done by the District Nurses/Community Matron when a
patient is outside the hospital environment due to the risk of potential infection or
displacement.
14 Risk Management Strategy Implementation
14.1 Implementation & Dissemination
Via professional practice group, Intravenous therapy link nurses, educators,
clinical leads, matrons, ward managers and through training department
14.2 Training and Support
Refer to section 13 for further details
14.3 Document Control & Archiving Arrangements
Once ratified, these guidelines will be loaded to the documents library. Any
previous versions will be electronically archived by the Policy Administrator in the
electronic Policy Drive Archive Folder.
A signed hard copy of the guidelines will be forwarded to the Policy Administrator
and an electronic copy will be saved by the Policy Administrator in the electronic
Policy Drive. Further copies of current and archived policies can be obtained
from the Policy Administrator including versions in large print, Braille and other
languages.
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14.4 Equality Impact Assessment
Peninsula Community Health aims to design and implement services, policies
and measures that meet the diverse needs of our service, population and
workforce, ensuring that none are placed at a disadvantage over others.
As part of its development, this strategy and its impact on equality have been
assessed. The assessment is to minimise and if possible remove any
disproportionate impact on employees on the grounds of race sex, disability, age,
sexual orientation or religious belief. No detriment was identified.
15 Process for Monitoring Effective Implementation
By use of the annual audit of the infection prevention society audit tools. Results of these
audits will be presented to Professional Practice forum.
16 Associated Documentation
This document references the following supporting documents which should be referred to in
conjunction with the document being developed.
PCH Intravenous drug Administration and Vascular Access Policy (2012)
PCH Infection control Policy
PCH Waste management Policy
PCH Blood Transfusion Policy
Safe Ordering Prescribing and Administration of Drugs in Community Hospitals
and Minor Injury Units, (April 2010)
All professional codes/ standards of practice
All relevant Patient Group Directions
17 References
Department of Health (2001) Guidelines For Preventing Infections Associated With The
Insertion And Maintenance Of Central Venous Catheters. Department of Health, London
Department of Health (2006) The Health Act: Code for the Prevention of Hospital Acquired
Infections. Department of Health, London
Department of Health (2007) High Impact Intervention No. 1 Central Venous Catheter Care
Bundle. Department of Health, London
Department of Health (2007) Taking Blood Cultures. Department of Health, London
Accessed at: http://www.cleansafcare.nhs.uk/toolfiles/105_283198BC_blood_cultures.pdf
National Institute for Clinical Excellence (NICE) (2003) Infection Control Prevention of
Healthcares Associated Infections in Primary and Community Care. NICE, London
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Pratt R.J. et al (2007) Epic 2. Guidelines for Preventing Health Care Associated Infections in
NHS Hospitals. The Journal of Hospital Infection. 65s, S1-S64
Accessed at: http://www.epic.tvu.ac.uk/PDF%20Files/epic2/epic2-final.pdf
Royal Marsden Hospital (2010) The Royal Marsden Manual of Clinical Nursing Procedures.
London. 6th Edition. Published by Blackwell Science. Chapter 44.
Royal College of Nursing (RCN) (2010) Standards for Infusion Therapy. Royal College of
Nursing, London.
Skills for Health (2007) CHS75: Insert a Central Venous Access Device. Skills for Health,
London Accessed at: http://tools.skillsforhealth.org.uk/competence/show?code=CHS75
Rapid Response Report: Risks with Intravenous Heparin Flush Solutions (Reference:
NPSA/2008/RRR02) issued on 24 April 2008
PHNT Intravenous Policy
http://nww.picts.nhs.uk/PHNetLive/DesktopDefault.aspx?tabid=1731
http://www.plymouthhospitals.nhs.uk/ourservices/clinicaldepartments/Pages/VascularAccess
Team.aspx
PHNT Vascular access guidelines 2011
PHNT I.V. Policy
PHNT Vascular Access Team- Information guides
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Appendix 1

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Appendix 2
Reference Guide for Peripherally Inserted Central Catheters (PICC’s)
Indications:
Securing the Line:
Dressings:
Patency:
Accessing the Line
Documentation
Contact Details
Patient requiring regular central access for longer than 4 weeks
Securing device e.g. Statlock/ Griplock, remain in place as long as the catheter is in situ.
Securing devices are preferred to sutures due to infection risk 2,13, . These devices will need to
be changed weekly in accordance with manufacturer’s instructions
Site must be cleaned with a 3ml applicator of 2%
Chlorhexidine in 70% alcohol e.g. Chloraprep and left to dry.
(Povidine iodine 10% solution if patient Chlorhexidine
General
sensitive)
A sterile dressings pack must be used for all line care
Visual phlebitis (VIP) (CCAT) score must be documented
within the patient record.
If wound oozing or bleeding, sterile gauze should be used.
Dressing must be checked and replaced 24-48 hours post
Post Insertion
insertion or sooner if integrity compromised.
Once oozing/bleeding stopped transparent permeable
dressing can be used.
Wound/ catheter site inspected daily in acute setting, weekly
Continued Care
in the community. Change dressing using sterile technique
cleaning with a 3ml 2% Chlorhexidine in 70% applicator
5-10mLs 0.9% w/v sodium Chloride (the last 1-2mLs being
FLUSH
the lock)
LOCK Once weekly as above if not in frequent use 21 .
Manipulations of the line should be kept to a minimum
Sterile technique must be used.
Needleless connectors to maintain closed system with a 10 ml syringe or larger
Access points must be decontaminated with 2% Chlorhexidine in 70% alcohol e.g. Sanicloth
All care (insertion, maintenance, access) must be documented within the patient record. A
visual phlebitis (VIP) or (CCAT) score must be recorded at each observation/ access of the line.
Measure external line at each visit and document
Designated consultant lead for the line/ vascular access team.
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Reference Guide for Tunnelled Central Lines
2R2
Indications:
Patient requiring regular central access for longer than 4 weeks
Dressings:
Patency:
General
Post Insertion
Continued Care
Open (un-valved)
Systems
Closed (valved)
systems
Site must be cleaned with at least a 3ml applicator of 2% Chlorhexidine in 70% alcohol
e.g. Chloraprep and left to dry. (Povidine iodine 10% solution if patient Chlorhexidine
sensitive)
A sterile dressings pack must be used for all line care
Visual phlebitis (VIP) or (CCAT)score must be documented within the patient record.
If wound oozing or bleeding, sterile gauze should be used.
Dressing must be checked and replaced 24-48 hours post insertion or sooner if integrity
compromised.
Once oozing/bleeding stopped transparent permeable dressing can be used.
Wound inspected daily in acute setting, weekly in the community
Dressing to be changed every 7 days (or sooner if required).
Tunnelled CVC’s may not require a dressing once the exit sutures have been removed 2 ;
(the patient age, patient choice and the risk of infection must be considered before this
decision is made).
FLUSH 10mLs of 0.9% w/v sodium chloride
LOCK ONCE WEEKLY IF NOT IN FREQUENT USE WITH
2-3mLs Heparin Solution (Heparin 10units/mL) if indicated in care plan
Using positive pressure cap
FLUSH & LOCK 10-20mLs 0.9% w/v sodium chloride (lock= last 1-2mLs)
Accessing the Line
Documentation
Manipulations of the line should be kept to a minimum
Sterile technique must be used.
Use needleless connectors to maintain closed system with a 10 mL syringe or larger
Access points must be decontaminated with 2% Chlorhexidine in 70% alcohol e.g. Sanicloth
All care (insertion, maintenance, access) must be documented within the patient record. A visual phlebitis score
(VIP) or (CCAT) must be recorded at each observation/ access of the line.
Contact Details
Designated consultant lead for the line.
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Reference Guide for Implanted Ports
2R3
Indications:
Securing the
Line:
Dressings:
Patient requiring regular central access for longer than 4 weeks
Fixed under the skin with dissolvable sutures.
Site must be cleaned with 3ml applicator of 2% Chlorhexidine in 70% alcohol e.g.
Chloraprep and left to dry. (Povidine iodine 10% solution if patient Chlorhexidine
sensitive)
General
A sterile dressings pack must be used for all line care
Visual phlebitis (VIP) or (CCAT) score must be documented within the patient
record.
If wound oozing or bleeding, sterile gauze should be used.
Dressing must be checked and replaced 24-48 hours post insertion or sooner if
Post Insertion
integrity compromised.
Once oozing/bleeding stopped and area has healed, no further dressing is required.
Continued Care
Site inspection required when accessing the line.
Patency:
Accessing the
Line
Documentation
Contact Details
FLUSH
5-10mL of 0.9% w/v sodium chloride and use Heparin 10 units/mL If needle left in
4 WEEKLY LOCK IF NOT
4-6mLs of heparin solution (Heparin 100 units/mL) direct into port
IN FREQUENT USE
Manipulations of the line should be kept to a minimum
Sterile technique must be used.
Access using specialised non-coring needles and extension sets (e.g. Huber) with a 10 mL syringe or larger
Access points must be decontaminated with 2% Chlorhexidine in 70% alcohol
All care (insertion, maintenance, access) must be documented within the patient record. A visual phlebitis score
(VIP) must be recorded at each observation/ access of the port.
Designated consultant lead for the line.
18 of 25

Appendix 3 Standard Operating Procedure for Flushing PICC line CVC SOP1
Procedure
Equipment and documentation:
Rationale
To prepare for task
Sterile dressing pack, Hand cleanser, Non sterile gloves, 10ml luer lock syringe,
drawing up needle,10-20mls 0.9%Sodium Chloride flush, 2% Chlorhexidine 70%
Alcohol wipe x 2, sharps bin, secondary securing dressing, care plan, prescription
chart
1. Wash hands apply gloves and apron and gain informed consent To reduce risk of cross contamination and gain patient co-operation
with the knowledge they or their carer understand the rationale for
the task
2. Prepare sterile field and equipment Advanced preparation for task and reduce risk of contamination
3. Expose line and switch off any infusion and observe VIP/CCAT score whilst To allow easy access when sterile and reduce risk of infusion drips
measuring external length of line
on sterile field. Note early signs of phlebitis. Determine if line has
moved
4. Clamp line and using ANTT disconnect any infusion seal giving set end with Allow access to port and reduce risk of contamination
sterile Bung
5. Remove gloves, wash hands and apply sterile gloves and apron. Reduce risk of contamination
6. Prepare flush using sterile gauze to open flush Reduce risk of contamination
7. Using sterile gauze pick up clave end and clean with wipe for 30 seconds and Reduce risk of contamination
allow drying for at least 30 seconds.
8. Attach syringe using luer locking system unclamp line and using a push pause Maintain a closed system and keep line patent by creating
technique flush the line with 10mls
turbulence in order to flush line thoroughly
9. Toward the last 1-2 mls clamp line but continue to flush To lock the system under positive pressure reduce risk of backflow
and clot formation
10. Use second wipe to clean end as before Reduce risk of contamination
11. Apply secondary dressing (Loose Bandage, tube fast) To protect from snags
12. Dispose of all sharps and document action in care plan Reduce risk of contamination to others and maintain continuous
record
*PHNT and Royal Marsden guidelines
19 of 25

Standard Operating Procedure for Flushing Tunnelled Line (Hickman) CVC SOP2
Procedure
Equipment:
Rationale
To prepare for task
Sterile dressing pack, Hand cleanser, Non sterile
gloves, 10ml luer lock syringe, 10-20mls
0.9%Sodium Chloride flush, 2% Chlorhexidine 70%
Alcohol wipe x 2, sharps bin, secondary securing
dressing, care plan, prescription chart
1. Wash hands apply gloves and apron To reduce risk of cross contamination
2. Prepare sterile field and equipment Advanced preparation for task and reduce risk of contamination
3. Expose line and switch off any infusion and To allow easy access when sterile and reduce risk of infusion drips on sterile field. Note early signs
observe VIP/CCAT score
of phlebitis.
4. Clamp line and using ANTT disconnect any Allow access to port and reduce risk of contamination
infusion, seal giving set end with sterile Bung
5. Remove gloves, wash hands and apply sterile Reduce risk of contamination
gloves and apron.
6. Prepare flush using sterile gauze to open flush Reduce risk of contamination and maintain sterile filed
7. Using sterile gauze pick up clave end and clean Reduce risk of contamination
with wipe for 30 seconds and allow drying for at
least 30 seconds.
8. Attach syringe using luer locking system
unclamp line. Draw back if possible to test and
using a push pause technique flush the line with
10mls
Maintain a closed system and keep line patent by creating turbulence in order to flush line
thoroughly
(if line contains Heparin, dispose of amount drawn back)
9. Toward the last 1-2 mls clamp line but continue To lock the system under positive pressure reduce risk of backflow and clot formation
to flush
10. If Heparin is used, use only required amount To ensure line remains patent and Heparin is not used as a flush
to lock e.g. 2-3mls
11. Use second wipe to clean end as before Reduce risk of contamination
12. Apply secondary dressing if required Comfort
13. Dispose of all sharps and document action in Reduce risk of contamination to others and maintain continuous records
care plan
*PHNT and Royal Marsden guidelines
20 of 25

Standard Operating Procedure for Taking blood via CVC (Discard Method) CVC SOP3
Procedure
Rationale
Equipment:
To prepare for task
Sterile dressing pack, Hand cleanser, Non sterile gloves,
Vacutainer, Blue needle adaptor, spare 5ml blood bottle for
discarding or 10ml luer lock syringe, required blood bottles, x 2
10 ml 0.9%Sodium Chloride flush, 2% Chlorhexidine 70%
Alcohol wipe x 2, sharps bin, care plan, prescription chart
1. Wash hands apply gloves and apron To reduce risk of cross contamination
2. Prepare sterile field and equipment Advanced preparation for task and reduce risk of contamination
3. Expose line and switch off any infusion and observe
To allow easy access when sterile and reduce risk of infusion drips on sterile field.
VIP/CCAT score
Note early signs of phlebitis.
4. Clamp line and using ANTT disconnect any infusion, seal Allow access to port and reduce risk of contamination
giving set end with sterile Bung
5. Remove gloves, wash hands and apply sterile gloves and Reduce risk of contamination
apron.
6. Prepare flush using sterile gauze to open flush Reduce risk of contamination and maintain sterile filed
7. Place sterile towel under port/s Reduce risk of contamination and maintain sterile filed
8. Using sterile gauze pick up clave end and clean with wipe for Reduce risk of contamination
30 seconds and allow drying for at least 30 seconds.
9. For Vacuum sampling: Attach Vacutainer system to port Maintain a closed system and remove any Heparin/Saline from line which can cause
unclamp line. Place 5ml blood bottle into Vacutainer and fill with result inaccuracies
blood then discard properly
10. Attach sample bottles for requested samples in correct To obtain sample. It is not necessary to clamp between samples, clamping at end
order and label as soon as possible, clamp on completion maintains closed system
11. Remove Vacutainer system and discard appropriately To prevent loss of blood and reduce risk to others
12. Attach 2 nd flush syringe, unclamp and flush with a full 10mls Maintain line patency and obtain a positive pressure in line
using a push pause technique clamping on final 1-2mls
13. Use second wipe to clean end as before. Reduce risk of contamination
14. Dispose of all sharps and document action in care plan Reduce risk of contamination to others and maintain continuous records
15. Ensure blood labels are done at bedside as soon as Reduce risk of wrong patient labelling
possible following action
*Royal Marsden Guidelines
21 of 25

Standard Operating Procedure for Flushing Implanted Ports (Portacaths) CVC SOP4
Procedure
Rationale
Equipment:
To prepare for task
Open and prepare;
Sterile dressing pack, Hand cleanser, Non sterile gloves,
x2 10ml luer lock syringe, 10-20mls 0.9%Sodium Chloride
flush, 2% Chlorhexidine 70% Applicator 3 ml, sharps bin,
non coring Huber needle with extension set, care plan,
cover dressing if required, prescription chart
1. Wash hands apply gloves and apron To reduce risk of cross contamination
2. Prepare sterile field and equipment Advanced preparation for task and reduce risk of contamination
3. Expose port area and observe for any redness or To allow easy access and note any signs of infection
swelling in area
4. Apply topical anaesthetic solution if patient requires 30- To reduce feeling of pain on insertion of needle
60 minutes prior to access
5. Locate port and septum and assess thickness of skin. To select correct length of Huber needle to insert
Refer to care plan
6. Wash hands and put on sterile gloves Reduce risk of contamination and maintain sterile filed
7. Flush port needle and extension set Check patency of needle and set
8. Clean port area of skin with applicator in a cross hatch To minimize risk of contamination and destroy skin flora
fashion
9. Ready the patient and explain you are about to insert Prepare patient and ensure needle is well inserted into portal
needle and push needle into port through the skin until it
touches back plate
10. Draw back on the syringe and check for blood return 2- To check needle is correctly placed
3mls . Dispose of Heparin mix blood solution.
11. Flush and observes any sign of swelling Check fro patency and correct positioning
12. If needle is not to remain in place monthly
To maintain patency over long periods of time (PHNT Guidelines for flushing and locking central
maintenance flushes should be done with 0.9% saline and lines)
locked with Heparinised saline 100iu/ml . When needle is
to remain in place flush with saline then lock with
(See guidelines for explanation of lock)
appropriate volume of 10iu/ml heparin.
13. Maintain pressure on plunger as syringe is
To prevent backflow of blood and possible clot formation
disconnected from injection cap
14. Remove needle and discard. Document needle size Reduce risk of contamination to others and maintain continuous records
and number of attempts on care plan
15. No dressing is required but a small plaster may be To prevent oozing from site
used
*The Royal Marsden Manual of Clinical Nursing Procedures 2010
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Appendix 4 Central Catheter Care & Audit Form
This form acts as an ongoing care and audit form. On completion copy this form and send it to the infection control team and file the original into the patient’s
notes.
Patient Name………………………………….NHS/Hospital No…………………………………….D.O.B……………………….
Type of central line………………………Reason………………………… Location on body ………………………………………..
Name of Hospital Line inserted at ……………………… Care plan from insertion clinician/ward………Y/N
Date
Time
Patient
Temp
VIP
score
Primary
dressing
changed
using a
sterile
technique
Clave
changed
For PICC
lines:
Measurement
out of arm @
exit
Access port
cleaned with
Chlorhexidine
wipe
Sterile
Procedure
Used for
Flush Y/N
Heparin
used as lock
& Strength
Positive
pressure on
completion
of flush
Clinician
Name
*Now send a copy of this form to Infection control and file original in patients notes.
23 of 25

Appendix 5 Types of Central Venous Catheters
CVC Device Use Picture Location Advantages Disadvantages
Peripherally inserted
central catheter
(PICC)
Non tunnelled central
venous catheter
e.g. Hohn catheter,
Triple Iumen catheter
Tunnelled central
venous catheter
e.g. Hickman,
Groshong and
Broviac line
Inserted via the
antecubital veins in the
arm and advanced into
central veins until the tip
is in the superior vena
cava. It’s position must
be checked by chest X-
ray
Inserted directly into the
vein, these devices are
mainly used in theatres
and intensive care units
for therapies of less
than 3 weeks duration.
It has a lifespan of 5-7
days but can remain insitu
for up to 14 days
(check manufacturers
instructions).
Not placed directly into
vein but are tunnelled
through the skin for
approx 5cm, the tunnel
reduces the risk of
infection.
1.Ease of insertion and
removal
2.Fewer insertion
complications
3.Low incidence of
related
infection/thrombosis
4. Can be used in home
setting
1.Can be inserted at
bedside
2. Good access, several
lumens
3. High flow continuous
access
1.Low infection rate
2.Patient comfort
3. No external fixation
4. Long term
1. Smaller lumen/flow
2. Mechanical Phlebitis at
insertion site
3. Problems with kinking
1. Highest rate of all CVC
infections
2. Requires external sutures
3. Uncomfortable for patients
4. Requires frequent changing 5-7
days
5. Difficulty maintaining
exit/dressing site
1. Surgical incision
2. Requires surgical removal
3. External portion of catheter
visible
Subcutaneous Port
e.g. Port-a-cath
Totally implanted
vascular access device
that is inserted into the
chest wall, lower
ribcage or antecubital
area. The port is
accessed via a noncoring
(huber point)
needle.
Error!
1. Patient comfort no
external sutures
2. No exit dressing
required
3. Requires less
maintenance
1. Use of needle to access port
2. Local skin ulceration through
repeated use
3. Shorter life span than a
tunnelled CVC
4. Requires surgical removal
24 of 25

Competency for Managing a Central Venous Catheter for I.V. trained staff Appendix 6
Competency Outcome Remarks
Understands the vascular system in relation to a CVC
Can identify and use all equipment required for accessing a CVC
Understands and explains the difference between ANTT non sterile and
sterile
Can identify and explain the different types of CVC
Has read the PCH CVC guidelines
Understands the rationale for using a CVC
Using the Standing operational procure in the PCH guidelines, can
manage a CVC in a safe and sterile way
Uses a CVC correctly and understands the term Flush and Lock
Uses the care/audit plan effectively
Can exp[lain and safely remove non tunnelled CVC line
Has changed CVC dressing using a sterile technique
Disposes of waste safely and appropriately
*These competencies can only be fulfilled if the registered staff member has shown they are competent to manage peripheral I.V. catheters,
completed ANTT training and fully read and understood the CVC guidelines.
Name of person being assessed…………………………Grade……………… Assessor Name………………………………Grade………………….. Date…….
25 of 25

Equality Impact Assessment Tool
To be completed and attached to any procedural document when submitted to the
appropriate committee for consideration and approval.
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V1-0 Page 1 of 1 17-Jul-12