Insertion and maintenance of peripheral venous catheters (PVC) in adults (16 years and over) (G084)

Insertion of a peripheral venous cannula (PVC) is a common healthcare intervention. However, there are significant risks associated with these devices. These include hematoma, phlebitis, extravasation, localised infection and bacteremia. PVC associated bacteremia’s are associated with significant morbidity and mortality.

The use of a PVC is a high risk procedure that requires scrupulous management.

This guideline will:

• describe the correct processes for the insertion, maintenance and removal of PVCs
• describe the monitoring arrangements that are required to provide assurance that PVC management is optimal
• describe the PVC reporting and governance arrangements at local and organisational level
• describe what training is provided within NHS Ayrshire & Arran.

A cannula is an invasive device that creates a portal of entry into the blood stream and must never be inserted “just in case”, nor should they be inserted for taking bloods.

It is essential that there is a defined, justified clinical reason for the insertion and continued presence of a PVC.

There are a number of reasons why peripheral venous cannulation may be required. The following lists potential indications, but is not exhaustive:

• Therapeutic – to administer IV drugs, fluids, blood products etc
• Diagnostic – to administer radio-opaque dye for scanning purposes
• Emergency access – to obtain access in patients who have the potential to become more unwell.

PVCs should be inserted when the anticipated duration of IV therapies is short. If the duration of treatment is anticipated to be long term, alternative intravenous access devices should be considered.

Factors such as past medical history, age and medications can cause some individuals to have poor venous access. If an individual is known to have poor venous access, seek help early.

Avoid more than 3 attempts at insertion with a patient.

A PVC is a single use device and must never be used more than once. After a failed attempt a new cannula must be used for any subsequent attempts.

The need for a PVC must be reviewed at least daily.

A PVC must be removed when clinically indicated or when no longer required. A PVC must be removed if the patient develops signs or symptoms of complication such as inflammation or infection.

Choice of device

The information gathered from the patient assessment will determine which cannula should be used.
The cannula should:

• permit optimal flow rates
• cause minimum patient discomfort
• be easy to insert
• give high, consistent and reliable performance
• have an integrated free port to provide needle-free access
• be a “safer sharps” design unless there are documented reasons as to why a non-safer device is chosen.

The following procedure is based on best practice guidelines. It is recognised that the procedure may vary slightly depending on the clinical area e.g. theatres, or the situation e.g. emergency cannulation. Cannulas inserted in an emergency must be replaced at the earliest opportunity and the actions taken clearly documented.

The PVC Insertion and Maintenance bundle now includes a (DRIFT) acronym:

• Diagnostics
• Resus
• IV Meds
• Fluids
• Transfusion.

This is designed to assist staff to make informed decisions as to whether a PVC is still required. If the PVC does not meet the DRIFT criteria then it must be removed.

A PVC insertion pack (SKU number 228645) is available and includes all the necessary equipment required for insertion. The pack contents include:

• drape
• single use disposable tourniquet
• 70% isopropyl alcohol and 2% chlorhexidine wipe
• swabs
• 10ml saline flush
• octopus extension
• semi permeable transparent dressing
• insertion sticker.

The PVC insertion pack does not contain a PVC.

It is at the discretion of each clinical area whether they use the PVC packs or not. The PVC insertion process and required equipment should not change whether a PVC pack is used or not.

The insertor must take an approved sharps disposal system along with all the required equipment.

Appropriate Personal Protective Equipment (PPE) will be located close to where the procedure will be carried out.

An apron and well-fitting gloves is the minimum PPE recommended to protect the wearer from risk of contact with blood or body fluids.

Perform hand hygiene as per the World Health Organization (WHO) 5 moments for hand hygiene.

Ensure patient is comfortable and limb positioned for comfort of both the patient and insertor.

Confirm the patient’s identity and gain consent to undertake the procedure.

Consider topical anesthesia or a heat pack to ease insertion of device.

Open the PVC insertion pack/prepare the equipment and check packaging and expiry dates (where applicable)

1. Perform hand hygiene as per the World Health Organisation (WHO) 5 moments for hand hygiene.
2. Place the drape under the chosen limb at the site of cannulation.
3. Prime the octopus or needleless injection cap with a syringe of 0.9% sodium chloride (NaCI) and place on the drape.
4. Apply the tourniquet and palpate to identify an appropriate vein.
5. Cleanse the skin area with a 70% isopropyl alcohol and 2% chlorhexidine wipe.
6. Wait until the skin is dry. The skin is not disinfected until the liquid has fully evaporated.
7. The chosen insertion site should not be touched after the skin has been cleansed. If this is unavoidable, sterile gloves are recommended or the skin should be disinfected again.
8. Perform hand hygiene.
9. Apply non sterile gloves.
10. Without touching critical parts, remove the needle protector from the PVC and inspect for any faults.
11. Insert the PVC using a non-touch aseptic technique.
12. Once flashback is obtained, advance the PVC a few millimeters to ensure entry into the vein, partially withdraw the stylet (needle) until a second flashback appears, then slowly advance the PVC off the stylet into the vein.
13. Release the tourniquet, then remove the stylet and place this directly into a suitable sharps disposal system.
14. Attach the primed octopus or needleless injection cap (if using) to the PVC.
15. Flush the PVC with 0.9% NaCI, using a pulsatile flush and ending with positive pressure.
16. Check that flushing the PVC does not cause the patient any pain or discomfort. If pain occurs, swelling or leakage is observed, the PVC is not correctly inserted and must be removed.
17. Apply an appropriate sterile semi-permeable dressing.
18. Dispose of used equipment into the appropriate waste containers.

Ensure the insertion sticker is fully complete with all relevant information. This can then be attached to paperwork for transfer (from Theatres/Emergency Department) to the receiving area then secured onto the relevant section of the insertion bundle.

• Always perform hand hygiene immediately before accessing a PVC for any care or maintenance purposes.
• PVCs must always be managed using an aseptic technique.
• Use DRIFT criteria to determine if the PVC is clinically required. If the PVC does not meet the DRIFT criteria then it must be removed.
• The site should be monitored at least daily, and every time the device is accessed.
• If the PVC dressing is loose, damp or blood stained, replace the dressing using an aseptic technique. The insertion site and surrounding area should be cleaned with 70% isopropyl alcohol and 2% chlorhexidine wipes and allowed to dry before applying the new dressing.
• Flush with 5-10 mls 0.9% sodium chloride prior to administration of drugs/infusions.
• Decontaminate the end of the octopus or needleless injection cap with a 70% isopropyl alcohol and 2% chlorhexidine wipe for a minimum of 15 seconds and allow to air dry (“Scrub the Hub”)
• Flush with 5-10 mls 0.9% sodium chloride after administration of drugs/infusions.
• Instruct the patient to inform staff immediately if the PVC site becomes painful, red or swollen.
• Complete appropriate maintenance bundle documentation daily.

1. Carry out hand hygiene.
2. PVCs must be removed using an aseptic technique.
3. Apply non sterile gloves.
4. Gently remove the dressing and the PVC using a slow, steady movement and apply pressure until bleeding has stopped.
5. Cover the site with a suitable dressing.
6. Dispose of gloves, PVC and dressing as healthcare waste.
7. Instruct patient to inform staff immediately if site starts to bleed, becomes painful, red or swollen even after removal at any point during their admission.
8. Document reason for, date and time of removal on the maintenance bundle.

PVCs should be inserted using an aseptic technique, and only when clinically required.

Avoid inserting PVCs over areas of trauma/inflammation, or sides of the body affected by stroke or mastectomy.

In patients with chronic kidney disease, PVCs should be inserted in the hand, avoiding the wrist/elbow.

Ensure the skin is decontaminated with 70% isopropyl alcohol and 2% chlorhexidine wipe and avoid touching the insertion site prior to PVC insertion.

Never re-use the same PVC. If cannulation is unsuccessful, use a new PVC.

Avoid more than 3 attempts at cannulation.

PVCs should not be used for obtaining blood cultures, unless this is the only practical method.

PVC must be removed when clinically indicated or when no longer required. A PVC must be removed if the patient develops signs or symptoms of complication such as inflammation or infection.

If a PVC site becomes infected, ensure that the PVC is removed, swab the site using a black charcoal swab, and inform medical staff as soon as possible.

Cannulation and venipuncture training is provided by the Resuscitation Team. Staff requiring training must be booked by their manager. On confirmation of a training place the staff member receives instructions to download and print the pre- course reading material and training pack.

There is also a PVC Learnpro module, which staff must have completed prior to attending cannulation training. The PVC Learnpro module should be completed each time it lapses.

Training consists of a 3 hour face to face session combining theory with practical experience on a part-task IV trainer.

The theoretic session will address:

• professional responsibilities
• indications for peripheral vascular cannulation
• choice of cannula
• choice of site
• complications
• infection control
• insertion and maintenance bundle
• supervision and assessment process.

The practical session includes a "4 stage teaching method":

• complications
• stage 1 - real time demonstration by instructor of full procedure adhering to best practice
• stage 2 - demonstration by instructor with commentary to explain each aspect with key learning
• stage 3 - candidate then talks instructor through the procedure. Instructor then reinforces key messages and corrects any errors/misunderstanding
• stage 4 - candidates practice under supervision of instructor until they feel comfortable with technique.

On completion of the practical session staff will be provided with the opportunity to ask questions and reinforce the practice/assessment phase.

Post-training phase

In their clinical area each trainee will be allocated a supervisor. The trainee is encouraged to undertake early frequent practice under supervision. The supervisor will provide formative feedback during supervised practice.

The trainee is encouraged to practice until they feel confident/competent.

A summative assessment will be carried out by the supervisor who will verify that the trainee has demonstrated that competency before independent practice will take place.

The Senior Charge Nurse (SCN) will retain a copy of competency assessment for records.

In order to ensure optimal management of PVCs, clinical areas must ensure that practice is monitored on a regular basis. This is achieved by monitoring the implementation and completion of PVC insertion and maintenance bundles.

Senior Charge Nurses (SCNs) must assess whether the insertion process, maintenance process or both should be monitored. In areas that insert multiple short term catheters e.g. Theatres, the insertion bundle is the most appropriate approach. Areas where PVCs are used frequently for inpatients (admitted overnight) monitoring of the maintenance bundle is required. A number of areas will require to monitor both processes.

Monitoring process

A random sample of 5 patients per week/20 per month should be selected. The PVC audit should be undertaken by a member of staff competent in PVC insertion and management. Data should be collected using the current version of the monitoring tool which must be obtained from the Clinical Improvement Portal.

Once completed, the bundle compliance findings must be entered into the Clinical Improvement Portal. When all compliance data for the month has been added to the portal, a compliance report should be printed and issued to the SCN.

The audit results should be used locally to determine local actions to improve compliance. This should include how sustained improvement will be demonstrated.

Reporting/governance arrangements

• It is essential that the results of the monitoring are reviewed on a regular basis to provide assurance of optimal practice and ensure early identification of issues that require intervention.
• The results should be displayed on the Ward/Department’s Improvement Board so that staff, patients and visitors can clearly see the data.
• PVC bundle compliance will form part of the regular SCN/CNN meetings.
• The CNM/Manager must be informed where the score falls below 85%.
• Each Local Governance Group should review PVC bundle compliance as part of its review of quality indicators.

The Infection Prevention and Control Team (IPCT) will undertake independent monitoring of PVC management. This may be in response to a specific incident or as part of a wider PVC assurance audit.

The results will be reported to the clinical teams and the Prevention and Control of Infection Committee (PCOIC).

Employees are reminded that they may have patients/carers who require communication in an alternative format e.g. other languages or signing. Additionally, some patients/carers may have difficulties with written material. At all times, communication and material should be in the patient’s/carer’s preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on clinical guidelines e.g. choice of gender of health care professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability or impairment that makes it difficult for them to be treated/examined as set out for a particular procedure, requiring adaptations to be made.

Patients’ sexual orientation may or may not be relevant to the implementation of this guideline; however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexual orientation may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality Impact Assessment Tool Kit. No additional equality & diversity issues were identified.