From the St Lukes IV Committee

IV Policy/Practice ChangeNEW CHANGESNEW CHANGES

SummarySummary

• Circumferential products not to be used to secure IVs• Manifolds will be removed in recovery room • Carrier solutions are to be used with low volume titrated medications• IV admixtures prepared outside the pharmacy are to be used within 1

hour• IV admixtures prepared outside pharmacy are to have distinctive colored

label with all information• Peripheral IVs will be left in no longer than 4 days (Adults only)• Chlorhexidine is used for IV starts • Chlorhexidine may be used on infants > 41 weeks gestation• Use alcohol to wipe injection ports before administering medication• IV start kit to be used (except NICU)• IV tubing is labeled with the date the tubing is to be changed• Clarification on how to remove central lines

From the St Lukes IV Committee

IV Policy/Practice UpdateIV TUBINGIV TUBING

Change every 24 hours• Intermittent infusion tubing

– Any tubing disconnected = intermittent– A sterile cap must be placed on end – DO NOT LOOP onto itself

• Parenteral nutrition with lipids• Lipids only (Usually only 10-12 hrs)• Intermittent Parenteral nutrition (Adult

and peds)• Continuous Parenteral nutrition – NICU

Change every 72 hours• Continuous infusion• Parenteral Nutrition continuous without

lipids (Adult and peds)

MISCELLANEOUS• Blood (Standard) tubing –

– change every 4 hours or every 2 units whichever is less

– Rapid Infuser – change every 3 hours or sooner if sluggish infusion

• Extension set – change with any tubing changed• Hemodynamic monitoring tubing + set up are

changed every 96 hours • See manufacturers instructions for medications

using specialty tubing and filters.

From the St Lukes IV Committee

IV Policy/Practice UpdateParenteral Nutrition - AdultParenteral Nutrition - Adult

• Orders written daily on parenteral nutrition order form.• Administration (hang) time should be no longer than 24 hours.• No filter for parenteral nutrition ONLY infusion.

– If lipids added to same line then a 1.2 micron filter is used– The lipids are piggybacked above the filter (to catch the precipitate)

• If lipids used, ALL tubing changed every 24 hours. – If no lipids are used then tubing changed every 72 hours.

• If parenteral nutrition is non-continuous (e.g. night time only/intermittent), then tubing changed daily.

From the St Lukes IV Committee

IV Policy/Practice UpdateParenteral Nutrition- Parenteral Nutrition- Peds/NICUPeds/NICU

• Orders written daily on parenteral nutrition order form.• Administration time should be no longer than 24 hours..• No filter for parenteral nutrition ONLY infusion (Peds).

– If lipids added to same line then a 1.2 micron filter is used– The lipids are piggybacked above the filter (to catch the

precipitate)• If lipids used, ALL tubing changed every 24 hours.

– If no lipids are used then tubing changed every 72 hours. • If parenteral nutrition is non-continuous (e.g. night time

only/intermittent), then tubing changed daily.• NICU –

– changes parenteral nutrition tubing every 24 hours and uses a 0.2 micron filter (Lipids do not get filtered)

From the St Lukes IV Committee

IV Policy/Practice UpdateRemoving a Central LineRemoving a Central Line

1. Lay patient as flat as they can tolerate.2. Remove old dressing.3. Cleanse site with chlorhexidine pad.4. Remove sutures or StatLock5. Have patient hold their breath when line is being

pulled (especially with jugular and subclavian lines).6. Remove line slowly and steadily.7. Hold firm steady continuous pressure to the site for

5 minutes (if on anticoagulant will need to be longer)

8. Apply antibiotic ointment if ordered9. Cover with sterile occlusive dressing.10. Before discarding the line, examine the tip to be

sure it is intact.

From the St Lukes IV Committee

IV Policy/Practice ChangePICC DressingPICC Dressing

Look at this picture, what was done correctly? Biopatch was used (blue side or writing up) Date/Initials present (date of dressing change) Statlock used Catheter is snug as possible to the entrance site

Tips for PICC line care If you are not able to see the site because of a

2 x 2 or gauze dressing then the dressing needs to be changed every 48 hours. Ideally gauze should not cover the insertion site.

Sterile dressing including the StatLock and BioPatch needs to be changed every 7 days or more often if soiled

Use a central line dressing kit!

From the St Lukes IV Committee

IV Policy/Practice ChangeCapsCaps

Microclave (B)• A neutral pressure cap used on

Peds/PICU/NICU.

• Heparinized saline is used for line maintenance.

• Caps are changed with dressing change or per unit protocol

• Swab injection ports with alcohol before accessing

Name the cap below!

CLC2000 (A)• A positive pressure cap • Used on adult central lines. • Normal saline is used for maintenance.• Line is not clamped until flush is completed and the

syringe removed from the cap• Swab injection ports with alcohol before accessing

Smart site (C)

• A negative pressure cap • Used on adult/peds IV lines and port-a-caths • See tables for flushing preferences.• Line is clamped as the last ½ ml flush is injected.• Swab injection ports with alcohol before

accessing

A B C

From the St Lukes IV Committee

IV Policy/Practice ChangeIV Site and Dressing CareIV Site and Dressing Care

Central LineCentral Line • Change dressing every 7 days• Biopatch should be placed around line

with hub of catheter snug as possible• Dressing must cover site completely• If 2x2 placed over insertion site then

change dressing within 48 hours.• IF visibly soiled or dressing loose

then change dressingDressing change procedure• Use Central Line Kit

• Get StatLock if PICC • Remove old dressing using clean gloves• Remember! This is a

– STERILE procedure so use – STERILE technique and – STERILE gloves.

Peripheral linesPeripheral lines• Change site every 4 days in adults

• Use an IV start kit

– Use IV label on tegaderm, -Note the date/time/initial of IV start

– Use chlorhexadine to prep site on patients older than 41 weeks

– Use StatLock (if pt here > 24 hrs)

• Change any IV started outside the hospital ASAP or within 48 hours.

• Peds IVs are not routinely changed. If it looks and feels good, leave it in.

• Dressing change is clean technique

From the St Lukes IV Committee

IV Policy/Practice ChangeSITE Change and AssessmentSITE Change and Assessment

When do I need to start a new IV?

A. Looks OK but the pump alarms every time the patient bends his arm.

B. Looks OK but the patient says it hurts.

C. It was started yesterday in McCall and runs great.

D. Looks a little puffy but runs OK.

E. Site is new but looks red

F. There is a good blood return but it’s slightly swollen.

G. Site is 4 days old but looks and runs great.

How often do I need to document site and flow rate of my IV in Soarian, ICMP or on the BOS?A. Every hour B. Every 24 hourC. Every 8 hour D. At shift change YES! C. At minimum every 8 hours

You guessed it – All of the above means the IV needs to be changed.

From the St Lukes IV Committee

IV Policy/Practice ChangeMedication AdministrationMedication Administration

**New**Any medication mixed outside of

pharmacy is For immediate use Administration should begin no later then

1 hour from start of preparation

**ALERT**• Use the correct diluent and amount• Use SAS (saline-additive-saline) method

to flush line before and after• Wipe the tops of previously opened bottles

with alcohol

• All medications must be labeled– Patients name– Location– Medication name– Medication dosage– Date and time– Initials of who prepared

From the St Lukes IV Committee

IV Policy/Practice UpdateCentral Line Kits

• Adult Central line – use central line kit – Not needed for tunneled catheters and

ports – Tunnel catheters and portacaths do

not need biopatch• Infection control recommendation• Time saving & cost effective• All items needed included

– Biopatch – best practice to use on PICC’s, non-tunneled central lines, arterial lines.

– Exception - No StatLock in kit

From the St Lukes IV Committee

IV Policy/Practice Change PowerPorts and Smart PortsPowerPorts and Smart Ports

Two types of Power Injectable Port-a-Caths PowerPorts (a) made by Bard SmartPorts (b) made by Angiodynamics

-Used at St. Lukes for Medical Imaging Procedures

-Identification required before can access with a power injectable needle (PowerLoc)

When can they be used with a PowerLoc needle:

There are two ways to identify a Power Injectable Port at St. Lukes

• Identification Card carried by the patient

Or

• Dictated Medical Record from MD who implanted the Port. Report must state it is a power injectable port.

A B

From the St Lukes IV Committee

Policy/Practice ChangeIV complicationsIV complications

Phlebitis – any pain even if site does not “appear” painful or red

Infiltrate –

Should an infiltrated IV be left in until a new one can be started? No, any infiltrated IV needs to be taken out immediately even if there is a delay in the restart.

Extravasation -At first it does not look bad but it can have bad results (Leaking of vesicant/IV fluid)

-See chemotherapy policy on medication extravasation

or NICU policy.

-Contact Provider

-Use pharmacy as resource

From the St Lukes IV Committee

IV Policy/Practice ChangeBlood Culture Draw from a Blood Culture Draw from a Central LineCentral LineClarify with Provider/MD

Do you want a peripheral blood culture done 1st? Second culture from central line?

Do not flush lumen before drawOne vacutainer with one set of bottles for each lumenBlood culture needs to be done before any other labsRemove old capPlace a new cap or draw hub to hubWhich to fill first?

Aerobic (blue –adults, pink – peds) Anaerobic (yellow)

From the St Lukes IV Committee

IV Policy/Practice ChangeBlood Draw – Central LineBlood Draw – Central Line

• Stop running infusions in all of the central line lumens.• Disconnect IV tubing from lumen being used for blood draw.• Clamp any lumens not being used for blood draw• Pull back and waste 5 ml of blood prior to collecting lab specimen.• If drawing coag studies (only with MD order) waste 10 ml of blood• Attach vacutainer set up and insert tubes according to order of fill.• Flush line with 10 ml NS. Use a vigorous push/pause technique.• If port – flush with 20 ml NS. • REMEMBER – if flushing through a CLC2000, flush, disconnect

syringe, then clamp line.• REMEMBER – unclamp other lines that were clamped

for draw and restart fluids. • LABEL SPECIMEN TUBES AT BEDSIDE – Verify name,

DOB, time and date of draw and your initials..

Parenteral Nutrition running? • Do not draw labs from lumen which TPN is running. • Flush lumen with 10-20 ml NS prior to drawing lab

From the St Lukes IV Committee

IV Policy/Practice ChangeBlood Draw – Central LineBlood Draw – Central Line

TroubleshootingTroubleshootingSLOW TO DRAW?

– Use a 10 ml syringe or larger to draw– Instead of using a vacutainer to hub, draw with syringe, then

transfer to blood tubes with a “female blood transfer device”

NO BLOOD RETURN?– 1st make sure line is unclamped– Try having patient change positions

• eg: raise arms above head, lie down or sit up, roll to opposite side

– Have patient cough and take deep breath

TPA needed?– Call MD/Provider if unable to draw and/or flush lumens. – TPA may be ordered (Use the Order Set: Alteplase (TPA) for

CVAD Line Clearance)

From the St Lukes IV Committee

IV Policy/Practice Update IV InsertionIV Insertion

WANT TO IMPROVE YOUR SUCCESS?

Wear snug gloves and goggles/safety glasses • Tight enough tourniquet (just above DBP but not > SBP)• Use a warming pack (chemical or blanket from warmer)• Place arm in dependent position / lower arm down (hang down off bed)• Pump fist 4 times then hold (not to tight)• Lightly tap skin over vein site• Superficial veins tend to roll because they are loose – immobilize in

stable position with non-dominant hand/thumb• If obese patient – use longer cannula and displace edema and extra

tissue while inserting• May need to repeat above steps if vein does not distend• Loose skin – stabilize by applying tract with fingers distally from

insertion siteMinimize Discomfort• Reduce pain by firmly rubbing during disinfecting – confuses nerves• No more than two attempts per RN

From the St Lukes IV Committee

IV Policy/Practice UpdateIV documentation

Soarian DocumentationIV starts• PICC/Central/Peripheral

– Chart IV start date, gauge, number of attempts (peripheral). – Length of catheter PICC (Located in chart after pt returns from Specials)

Every 8 hours (minimum): • Peripheral IV

– Site condition: is it red ? is it tender (phlebitis)? Is it infiltrated?– Discontinue if have problem; don't wait for the new IV– Chart discontinuation in Soarian, otherwise it carries over into the next

assessment that the IV is still there• PICC/Central:

– Patency of lumens– How do they flush? Draw blood?– When is the next dressing change due?

Interventions• Chart when dressing and cap change completed • Make a focus note when provider contacted about infiltration or

phlebitis or frequent IV starts r/t infiltration and/or phlebitis issues

From the St Lukes IV Committee

IV Policy/Practice UpdateKeeping an open IV lineKeeping an open IV line

TKO – IVF Rate– Adults - 40ml/hour (~1000ml/24hrs)

– Neonate or infant up to 3 months – 1-5ml/hr

– Infants 3 months to 1 yr of age – 5ml/hr

– Child from 1 to 6 years of age – 10ml/hr

– Child from 6 to 12 years of age – 15ml/hr

– Child from 12 to 17 years of age – 20ml/hr

– NICU – follow orders

Caution – Is MD aware of TKO rate for CHF patient?

From the St Lukes IV Committee

IV Policy/Practice ChangeCarrier LineCarrier Line

Why/What is a Carrier Line?• Low IV Infusion rates need to have a carrier solution to

maintain access and to keep a constant infusion (eg. PCA, medication infusions)

Adults – any infusions with less than 10 ml/hr• Carrier solutions may be 0.9 Normal Saline if no infusion

identified by the provider/MD (does not require a separate MD Order)

• 25 – 30 ml from a primary line needed to “flush-in” medication from secondary line (otherwise patient only receives a partial dose)

Remember – all IV solution bags must be changed every 24 hours

From the St Lukes IV Committee

IV Policy/Practice UpdateSecondary InfusionSecondary Infusion

• Are you intermittently accessing a saline lock to start a medication infusion?

• Do you know that IV solution bags need to be changed every 24 hours (especially when it is for intermittent medication infusions?)

• Do you know to cap the tubing with new male/female adapter every time you disconnect the IV tubing?

• Do you know if it is an intermittent infusion then the tubing, carrier solution and secondary tubing needs to be changed every 24 hours?

• Do you know that you can back flush your secondary tubing and reuse the tubing for all your secondary medications? You should not have more then ONE secondary tubing.

From the St Lukes IV Committee

IV Policy/Practice ChangeWhat’s wrong in the What’s wrong in the

pictures?pictures?Coban or Co-Flex

Material meant to be used as a temporary pressure dressing (less that 20 minutes) only.

Coban and Co-Flex used to for lab draws- must be removed ASAP.

Do use X-span Tubular Dressing Retainer or Kerlix to secure IV sites

CLC 2000- post flush

If you see the white portion depressed then it has been clamped before removing the syringe. If it was found this way, replace the CLC 2000 with a new one!

From the St Lukes IV Committee

IV Policy/Practice UpdateInfection Prevention TipsInfection Prevention Tips

• 2% chlorhexidine – scrub skin 3.15% scrub skin for 15 for 30 seconds seconds

FYI: Multi-dose vials requires expiration date of no longer than 28 days from date opened.

Always scrub caps with alcohol before use