Hennepin Healthcare System
Policy Title: Vascular Access Insertion, Use, and Management
Policy Sponsor: Infection Prevention
Review Body(s): Infection Prevention Committee, Policy Committee
Final Approval Body: Medical Executive Committee
Original Approval Date: 2003
Last Reviewed/ Revised: 04/22/2014
POLICY
This policy represents best practices for the use of vascular access lines and is the minimum
standard of care for all patients at HCMC to reduce the risk of complications, including but
not limited to, infections.
Table of Contents
Definitions
Indications for Use
Orders
General Principles
Central Line Insertion
Central Line Replacement
Use, Maintenance, and Access
Site Care and Dressing
Culturing for Suspected Infection
Complication
Removal
Patient Education
Training and Competency - Nursing
Training and Competency - Provider
Monitoring
References, Related Policies and Procedures
Central Line Insertion Checklist
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2-3
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3-4
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6-7
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Supporting
Document
Definitions
APP: Advanced Practice Provider
Central Venous Catheter: Are non-tunneled lines such as a PICC, IJ, SCV, Quinton, cordis, Swanganz, femoral venous catheter, cooling catheter, temporary dialysis catheter, UAC, UVC; or tunneled
such as a Hickman, Broviac,or Groshong
The type of line does not determine if it is a central line, it is where the line terminates. A
central line is any intravascular catheter that terminates at or close to the heart or in one of
the great vessels which is used for infusion, withdrawal of blood, or hemodynamic
monitoring. The following are considered great vessels: aorta, pulmonary artery, superior
vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins,
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external iliac veins, common iliac veins, femoral veins, and the umbilical artery/vein in
neonates.
CHG: Chlorhexidine gluconate: an antiseptic frequently combined with 70% alcohol used to prepare
the skin in persons >2months of age.
CLABSI: Central Line Associated Blood Stream Infection
HD: Hemodialysis
IJ: Internal Jugular
LIP: Licensed Independent Practitioner
Mosby: HCMC’s online nursing procedure manual
Non-Sterile Line: Any central line placed with breaks in the sterile procedure when the sterility is
unable to be re-established
PICC: Peripherally inserted central catheter for which the tip resides in the lower 1/3 of the superior
vena cava or right atrium (SVC/RA junction). In infants, the PICC may end in the inferior vena cava.
SCV: Subclavian
Stop the Line: A complete halt in the procedure when any part of the process is not followed
and/or a discrepancy is discovered. The procedure will not continue until all the steps of the process
are completed and any discrepancy resolved. (See Universal Protocol Policy # 009582)
TKO: To keep open
TPN: Total parenteral nutrition
UAC: Umbilical Artery Catheter
UVC: Umbilical Venous Catheter
PROCEDURES
1. Indications for Use
a. Clinical conditions warranting placement or continuation of a central access include the
following:
i. Need for multiple access ports
ii. To administer large amounts of fluid quickly
iii. Need for safe delivery of medications/solutions
iv. Vasopressor administration
v. Central venous monitoring
vi. Monitoring induced hypothermia
vii. Dialysis
2. Orders
a. All vascular lines shall have an order placed defining location, use of catheter, and
maintenance.
b. All temporary IJ, SCV, and PICC lines require catheter termination (site) documentation as
soon as safely possible.
c. Patients admitted with existing lines (tunneled or non-tunneled):
i. Place an order for IV team consult prior to use (not including NICU patients)
ii. If line is in use upon arrival, verify for patency, continued use, and request IV team
consult
d. Orders must be placed by the renal team for use of dialysis catheters for fluid administration
or blood draws in non-emergent situations.
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e. Daily assess the need for all central lines. Place an order for removal when clinically
indicated.
3. General Principles
a. Perform hand hygiene either by washing hands with antimicrobial soap (e.g. 2%
chlorhexidine gluconate) or with alcohol based hand sanitizer before and after palpating and
examining insertion sites, as well as before inserting, accessing, replacing, or dressing an
intravascular catheter.
b. Skin preparation of patient prior to line insertion
i. If patient’s skin is visibly soiled, clean with soap and water or CHG bathing cloth
prior to prepping.
c. All patients with a central line, shall have daily bathing with CHG (prefer CHG bathing cloth)
unless use is contraindicated by allergy or age <35 weeks (gestational age) AND <2 weeks of
life.
4. Central Line Insertion
a. Selection of insertion site
i. Subclavian
1. lowest risk of infection-but higher procedural risk
ii. Internal Jugular
iii. Femoral
1. To be used only in emergent conditions and removed within 2 days of
placement if other sites available.
2. Cooling catheters used for the hypothermia protocol may be inserted in the
femoral vein until the patient has been rewarmed.
b. Insertion Checklist
i. A dedicated independent observer is required to be at the bedside during the
insertion of all temporary, non-tunneled central lines.
ii. The observer can be an MD/DO, RN, APP, or Medical Student who has received
training in the monitoring of safe insertion practices.
iii. It is the responsibility of the inserter to secure the independent observer prior to
beginning the procedure.
iv. In the event of a medical emergency where adherence to the checklist cannot be
assured, label the line as non-sterilely placed using a yellow “change in 48 hour
sticker”.
v. The observer will monitor for the safe insertion of the central line and use the
Central Line Insertion Checklist employing the Stop the Line process of the Universal
Protocol.
vi. The observer will immediately notify the operator of any deviation from the
mandatory steps in the checklist, stop the procedure as necessary, and assure
compliance before the procedure can proceed.
vii. The checklist observer shall contact the attending physician if concerns arise related
to insertion.
c. Use maximum sterile barrier precautions including the use of a cap, mask, sterile gown,
sterile gloves, and a large sterile drape for the insertion of all central catheters, PICC lines,
pulmonary artery catheters, hemodialysis catheters, guidewire exchanges, and umbilical
catheters.
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d. For the insertion of peripheral arterial lines, a minimum of a cap, mask, sterile gloves and a
small sterile fenestrated drape should be used.
e. Use a new set of sterile gloves before handling the new catheter when guidewire exchanges
are performed.
f. When using topical anesthetics, apply prior to cleansing the site with antiseptic.
g. Cutaneous antisepsis
i. The antiseptic of choice to prep the skin before insertion of an intravascular
catheter is a 2% chlorhexidine gluconate (CHG) / 70% alcohol (e.g. Chlorascrub
swab). Use repeated back and forth strokes with the CHG for 30 seconds (2 minutes
for wet areas such as the groin) and then let dry for at least 30 seconds.
ii. If unable to use CHG because of patient sensitivity or age <35 weeks (gestational
age) AND <2 weeks of life, thoroughly cleanse site with 70% isopropyl alcohol,
follow with 10% povidone iodine, and allow to dry for at least 2 minutes.
h. Ultrasound guidance is recommended for all central line placements.
i. A CXR is required to verify placement upon completion of catheter insertion for all
subclavian, jugular, UAC, UVC, and PICC lines. Reviewing the CXR and appropriate follow-up
is the responsibility of the physician/RN that placed the catheter.
j. New technologies and products related to venous access must be approved by the Supply
Chain product committee prior purchasing for use.
5. Central Line Replacement
a. Line replacement should be at a new site.
b. Replace any short term catheter if purulent drainage (possibly indicating infection) is
present at insertion site.
c. Do not routinely replace central venous or arterial catheters solely for the purpose of
reducing the incidence of infection. However, use clinical judgment to determine when to
remove a centrally inserted catheter that could be a source of an infection.
d. Do not routinely replace catheters in patients whose only indication of infection is fever.
e. Emergently placed lines
i. When catheters are inserted during a medical emergency in which adherence to
aseptic technique cannot be ensured, the replacement of the catheter within 48
hours is the responsibility of the attending physician.
ii. Non-sterilely placed central lines must be tagged by the inserter with a yellow
“change in 48 hour sticker”.
iii. UVC’s placed emergently in the delivery room should be replaced when the infant is
stabilized in the ICU.
f. Cooling catheters are
i. Placed per Induced Hypothermia Protocols.
ii. Removed promptly once patient is warmed.
g. Lines placed under unknown conditions should be changed within 48 hours, when
alternative site access is available.
h. All lines present on admission shall be evaluated. If sterile placement/maintenance is
questionable, best practice would be to change the line within 48 hours when an alternate
access site is available.
i. All temporary HD catheters should be changed to a tunneled catheter within 14 days of use
when patient condition warrants ongoing need for dialysis access.
j. Lines with compromised dressing integrity
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Consider replacing central venous access when 2 or more unplanned dressing changes
have occurred between the normally scheduled dressing schedule.
k. Rewiring
i. Do not use guidewire exchanges to replace a non-tunneled catheter suspected of
infection.
ii. Central venous lines may be changed over a wire if the patient is febrile and it is
unclear whether the line is the source.
iii. For occlusion or mechanical failure, it is appropriate when the central venous access
is a continued necessity.
l. Consider placement of a tunneled catheter or PICC line in place of the IJ or SCV when the
need for the central access is:
i. Expected to extend beyond the ICU stay
ii. Expected to extend beyond hospital stay
iii. Expected during a long term NICU stay
6. Use, Maintenance and Access
a. Continuation of a central access must be assessed/reassessed at a minimum of every 24
hours.
b. Access
i. Always scrub the hubs on the IV system with CHG swab (preferred) or 70% isopropyl
alcohol for 10 seconds before entering. Allow the antiseptic to dry for 20 seconds
prior to access.
ii. Limit the number of times the line is entered if possible.
iii. All stopcocks must be capped with sterile caps immediately when not in use.
iv. See Venous Access Grid or NICU Venous Access Grid for other access standards
c. Dialysis line access: Due to the higher risk of infection with temporary dialysis lines, obtain
an order from renal team prior to accessing dialysis catheters for IV use or blood draws in
non-emergent situations. Only nurses who have been deemed competent may draw from
these catheters.
d. Tubing Changes
i. IV therapy will be initiated within 1 hour of spiking the IV bag with tubing. If the
setup is pre-primed for a prospective patient, it must be used within 1 hour of
spiking and the IV bag and tubing must be labeled with the date, time and initials of
the person setting it up.
Exception: “hazardous to handle” IV medications which are prepared in the
Pharmacy Clean Room with primed tubing. USP/ASHP/NIOSH support both the
preparation of these toxic items in a contained environment (priming in the
clean room to decreases exposure to staff and the environment) and 24 hour to
7 day stability following manipulation in the clean room, depending on the
product.
ii. Change all tubing at the time of a line change/replacement
iii. Label all IV tubing with the time of change AND when they are due to be changed
using the HCMC IV change labels.
e. Needleless connectors
i. Attach needleless connectors to all stopcocks and arterial lines (includes central
lines, dialysis, PICC, tunneled and implanted ports).
ii. Place Tego needleless connectors on all hemodialysis lines.
iii. Change connectors with the tubing and as needed.
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iv. Flush needleless connectors as needed to clear blood. If blood cannot be cleared,
then change connector.
Infusion Type
TPN
IV Lipids (fat
emulsions)
Dirpirvan (Propofol)
Blood and Blood
Products
IV Ativan continuous
infusion
SOLUTION AND TUBING CHANGE TIMES
Expiration/Change Time (in hours)
Bag/Soln *Tubing and
Other
2dary sets
24 hr
96 hr
Designate one port exclusively for
parenteral nutrition with multilumen
catheters
12 hr
24 hr
12 hr
12 hr
w/each
unit
4 hours or
after 2 units
whichever
occurs 1st
24 hr
When Diprivan is transferred to another
syringe or container, it must be labeled
with an expiration time of 6 hours. The
responsible nurse must discard it after 6
hours regardless of when that time falls
within the nurse’s shift.
Filtered pump tubing should be used with
diluted Ativan due to the possibility of
precipitation
TKO
96 hr
96 hr
Continuous
96 hr
96 hr
Intermittent
24 hr
24 hr
See exception in hazardous to handle
Art Line and
96 hr
96 hr (and
Including continuous-flush device and
Pulmonary Art Cath
transducer)
flush solution
*change at time interval or upon new line/line replacement
7. Site Care and Dressing
a. Assess all intravascular device insertion sites a minimum of every shift for signs of
infiltration, phlebitis or infections and document observation.
i. Infiltration: swelling, coolness, pain
ii. Phlebitis: redness, inflammation, swelling, pain
iii. Infection: redness, drainage or pus at the exit site, pain
b. Do not submerge the catheter under water. Showering is permitted only if the catheter and
connecting device (e.g., injection cap) can be covered with an impermeable cover to prevent
moisture on the catheter and connecting device.
c. Dressing change frequency
i. Dressings shall be changed immediately if they become loose, soiled and/or
condensation builds up under the dressing.
ii. Gauze dressings are to be changed at a minimum every 2 days.
iii. Transparent dressings are to be changed at a minimum of every 7 days.
iv. Dressings are not applied to umbilical catheters.
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d.
e.
f.
g.
h.
i.
v. In pediatric patients, dressing changes may vary when the risk for dislodging the
catheter outweigh the benefit of changing the dressing.
All central lines, excluding ports, should have a Biopatch placed unless use is contraindicated
by allergy or age <35 weeks (gestational age) AND <2 weeks of life.
Antimicrobial ointment or cream
i. Do not routinely apply to non- dialysis lines.
ii. Antimicrobial ointments can be used for hemodialysis catheter insertion sites.
Label dressing with date change AND change due date.
Dressing disruption management/notification
Notify the provider when 2 or more unplanned dressing changes have occurred
between the normal dressing schedules for consideration of line replacement.
Refer to Mosby for complete dressing change procedure.
Document site care, dressing change, condition of the site and any needle change in EPIC
Doc Flowsheets.
8. Blood cultures for suspected line related sepsis
a. Use clinical judgment prior to the collection of cultures. Low grade temps (e.g < 38.6) may
not always require blood cultures in absence of clinical signs of sepsis.
b. If blood cultures have already been obtained within last 24 hours for fever workup, do not
repeat unless there is clinical deterioration.
c. Paired blood cultures to be drawn at 2 peripheral sites.
d. If peripheral site are not available, line culture may be drawn after port prepped with CHG
for 10 seconds and allowed to dry for 20 seconds. Document that the culture was drawn
from the line.
9. Complications
Appropriate monitoring for complications will be part of the daily documentation.
10. Removal
a. Assess patient and document reason for continuation at minimum every 24 hours.
b. Remove at first clinical opportunity.
c. Removal process
i. Refer to Mosby for complete procedure.
d. Replace any short term catheter if purulent drainage (possibly indicating infection) is
present at insertion site.
e. Do not routinely replace central venous or arterial catheters solely for the purpose of
reducing the incidence of infection. However, use clinical judgment to determine when to
remove a centrally inserted catheter that could be a source of an infection.
f. Do not routinely replace catheters in patients whose only indication of infection is fever.
g. Do not use guidewire exchanges to replace a non-tunneled catheter suspected of infection.
h. Central venous lines may be changed over a wire if the patient is febrile and it is unclear
whether the line is the source.
i. Replace all central catheters if the patient is hemodynamically unstable and a catheterrelated blood stream or insertion site infection is suspected.
j. Remove umbilical catheters as soon as possible when no longer needed or when vascular
insufficiency is likely.
i. Limit use of umbilical artery for central line access to < 5 days whenever clinically
possible.
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ii. Umbilical vein should only be used for central line access for < 14 days.
k. Once an MD orders a central line to be discontinued, RN’s that have demonstrated
competency may remove PICC, temporary subclavian and internal/external jugular central
catheters. This procedure is not intended for infants and neonates.
11. Patient Education
a. Staff shall provide education to the patient for their role in prevention a CLABSI such as:
i. Do not touch the line and remind your family and friends not to touch.
ii. Report any time the dressing is not lying flat or is moist.
iii. Ask staff to wash their hands or use foam before they touch your line.
iv. Watch for staff to use the line safely - everyone should clean the port each and
every time before entering the line with a syringe or other tube.
v. Ask staff every day if you still need the line.
vi. Let your nurse or doctor know if the area feels sore or you notice redness.
vii. If you need to go home with your line, you will receive further instruction for home
care.
12. Training and Competency - Nursing
a. Staff and LIPs who are involved in managing lines shall be educated in infection
prevention measures upon hire, annually thereafter and when involvement in these
procedures is added to an individual’s job responsibilities.
b. Staff will periodically be assessed for knowledge of adherence to insertion and
maintenance best practices.
c. Nursing training and competency requirements for insertion, observation of central line
insertion, use, maintenance, and removal (I, O, U, M, and R respectively).
Peripheral Lines
Unit
Central Lines
Unit
Non-tunneled
Tunneled
Burn Step down
Responsibility
IV Team for I,M
Unit for U,R
Burn Step down
O, U,M,R
U,M
Clinics
I,U,M,R
Clinics
U,M,R
U,M
ED
I,U,M,R
ED
O,U,M,R
U,M
Interventional Radiology
I,U,M,R
Interventional Radiology
O,U,M,R
U,M
ICU (all)
ICU (all)
O,U,M,R
U,M
Med-Surg
I,U,M,R
IV Team for I,M
Unit for U,R
Med-Surg
O,M,R
U,M
Peds
I,U,M,R
Peds
O,U,M,R
U,M
PACU
I,U,M,R
PACU
OR
Managed by APP
OR
O,U,M,R
Managed by
APP
U,M
Managed
by APP
Surgical Admissions
I,U,M,R
Surgical Admissions
O,U,M
U,M
d. Specialty lines (eg: implanted) require training at the unit level by the users prior to use.
e. IV team training and competency
i. All RN staff will complete training and competency for insertion, care
and maintenance of a PIV, Midline catheter, ultrafiltration catheter, PICC 's with
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or without image guided venipuncture, and act as a clinical resource for the
identification and management of all Vascular access devices.
13. Training and Competency – Provider
a. Physician and APPs who are involved in managing lines shall be educated in infection
prevention measures upon hire, annually thereafter and when involvement in these
procedures is added to an individual’s job responsibilities.
b. Staff will periodically be assessed for knowledge of adherence to insertion and
maintenance best practices.
c. Residents
i. All residents must have successfully placed a simulated central line and
ii. Demonstrate competency per the Resident/Fellow Scope of Practice
14. Monitoring
a. Outcome Measures
i. All positive blood cultures are monitored by Infection Prevention. These
cultures are reviewed using the Centers for Disease Control National Healthcare
Safety Network surveillance definitions for infection.
ii. All CLABSI will receive a systems case review. The review will occur within a
week of occurrence and will include the involved staff, providers, Performance
Measurement and Improvement, and Infection Prevention.
iii. Centers for Medicare and Medicaid reporting
1. Infection Prevention reports laboratory confirmed CLABSI to CMS per
current reporting requirements.
2. Coding reports all CLABSI meeting CMS Health Care Acquired (HAC)
requirements.
b. Process Measures
i. Measurement of best practices required by regulatory bodies (including, but not
limited to The Joint Commission) will be monitored by the patient care units and
Infection Prevention and reported to Executive Leadership on a routine basis.
Examples of best practice include, but are not limited to: education, use of the
insertion checklist, hand hygiene, and device utilization.
Related Protocols:
1. Induced Hypothermia Protocol
2. Induced Hypothermia protocol for Brain Injury
Related Policies:
1. Intravenous Infusions: Standard of Care
2. Resident/Fellow Scope of Practice
3. Intravascular Access: Peripheral
4. Medication Management Selection Policy – Addendum A
5. Universal Protocol Policy # 009582
References:
1. Centers for Disease Control and Prevention. Guideline for the Prevention of Intravascular CatheterRelated Infections. MMWR, 2011;51 (No. RR-10)
2. Infusion Nursing Standards of Practice. The Journal of Infusion Nursing 2011; vol 43, No 1S
3. USP: United States Pharmacopeia, USP 797
4. ASHP: American Society of Health System Pharmacists
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5. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals.
Infection Control and Hospital Epidemiology 2008; 29:S22-S30
6. CMS Conditions of Participation
7. The Joint Commission National Patient Safety Goal 7.04.01
8. IHI Preventing Central Line Infections – How to Guide, 100,000 Lives Campaign
9. Diprivan 1% product insert
10. National Kidney Foundation KDOQI Guidelines 2000
http://www.kidney.org/professionals/kdoqi/guidelines_updates/doqiupva_i.html#doqiupva6
http://www.kidney.org/professionals/kdoqi/guidelines_updates/doqiupva_iii.html#14
Communication/ Staff Education:
Patient Education: CLABSI prevention see section 12 and Insertion Checklist
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