Clinical procedure - central venous access device (CVAD) - dressing and needleless connector change

The following is a list of recommended equipment required to undertake this procedure:

• trolley
• cleaning agent as per local policy
• personal protective equipment (PPE)
• basic sterile dressing pack
• non-sterile gloves
• sterile gloves
• sterile transparent semipermeable dressing
• 2% chlorhexidine gluconate and 70% isopropyl alcohol swabs sticks
• 2% chlorhexidine gluconate and 70% isopropyl alcohol solution
• antimicrobial disc or gel pad
• alcohol-free skin protectant film swab stick
• adhesive engineered securement device (ESD) (if required)
• needleless connector/s
• 10 to 20 mL luer lock syringe/s 
• 10 mL 0.9% sodium chloride ampoules
• blunt drawing up needle
• waste bag
• sharps container

1. Consult patient medical record, noting external catheter length at time of insertion, allergies or sensitivities to tapes, solutions, prescribed therapies with skin adverse effects and current dressing materials, and securement device.
2. Perform hand hygiene opens in a new tab or window
3. Decontaminate and disinfect trolley as per local policy
4. Gather equipment
5. Perform hand hygiene opens in a new tab or window
6. Using non-touch technique, prepare equipment on tray 
7. Proceed to patient and perform hand hygiene opens in a new tab or window
8. Check patient identification and flushing/locking solutions as per local policy
9. Explain the procedure and obtain verbal consent
10. Ensure patient is in a comfortable position
11. Perform hand hygiene opens in a new tab or window 
12. Put on PPE including non-sterile gloves

Removal of dressing materials

13. Using a non-touch technique remove:
    1. dressing: using a slow technique, with dominant hand loosen the edges while, supporting the skin with opposite non dominant hand, peel towards the catheter exit site (Key-Site), avoid touching the exit site (Key-Site) with gloves
    • bordered dressings: keep the dressing material close to the skin by pulling it back over itself
    • non-bordered dressings: stretch the material horizontally: walk fingers under dressing whilst supporting skin with non dominant hand
    2. catheter secured by adhesive ESD: using non-touch technique, apply sterile strip (from adhesive ESD pack) or sterile strips over catheter

© https://www.bd.com 

​Adhesive ESD (if present) using a slow technique, loosen the edges, support the skin with opposite hand, avoid touching the catheter exit site with gloves

Note: adhesive removers, e.g. normal saline, adhesive removers spray or swabs may be used if required

14. Clip hair on skin under dressing (if appropriate)
15. Assess:
    1. exit site: for any visible abnormalities, e.g. redness, exudate, swelling and/or tenderness, take a swab for bacterial investigation and discuss with vascular access expert, nurse practitioner, clinical nurse consultant, and medical team
    2. skin under dressing: for any signs of impairment, e.g. alterations is colour, warmth, texture, odour, exudate, lesions, tears, discomfort. If abnormalities noted: refer to CNSA Skin Management Algorithm : do not delay action

Measurement

3. external length of catheter: compare measurement with the length at time of insertion

PICC and CICC: count number of dots (1cm intervals) from anchoring hub to skin

tc-CICC: look for presence of the cuff at exit site (Key-Site)

If variance in length noted or cuff present, discuss with medical officer

© K Curtis 2021

16. Remove non-sterile gloves
17. Perform hand hygiene opens in a new tab or window 

Skin antisepsis & dry time

18. If using clean swab sticks, attend to skin antisepsis at this stage using non-touch technique. Disinfect skin at the exit site and all skin under dressing with 2% chlorhexidine gluconate and 70% isopropyl alcohol swab stick, using gentle friction for at least 30 seconds and allow to fully air dry. Clean swab sticks are not placed on the Critical Aseptic Field
19. Perform hand hygiene opens in a new tab or window 
20. Put on sterile gloves 
21. If exudate present at catheter exit site or along catheter, remove with gauze soaked in 0.9% sodium chloride and squeezed out
22. If using sterile swab sticks, attend skin antisepsis at this stage. Disinfect skin at the exit site and all skin under dressing with 2% chlorhexidine gluconate and 70% isopropyl alcohol swab stick, using gentle friction for at least 30 seconds and allow to fully air dry.   
    1. if subcutaneous ESD present, lift catheter in a hinge motion (avoid twisting) to cleanse 360^o around exit site (Key-Site) and all skin under the dressing

© https://securacath.com/

23. Clean the external length of the catheter (and external part of subcutaneous ESD if present)
    1. hold catheter with gauze soaked in 2% chlorhexidine gluconate and isopropyl alcohol solution with excess squeezed out in non-dominant hand
    2. disinfect catheter with gauze soaked in 2% chlorhexidine gluconate and isopropyl alcohol solution with dominant hand, cleaning from exit site towards the needless connector 
    3. avoid touching catheter with sterile gloves and avoid pulling on the catheter and subsequent migration when handling the catheter
24. Allow skin and catheter to completely dry (shiny to matte)
25. Place cleaned, dry catheter onto sterile drape

Skin protection

26. If securement strip over catheter (from step 13.b) will be under the dressing field, using non-touch technique (e.g. forceps) remove with care to prevent catheter movement or migration and perform skin antisepsis over that area of skin.  Allow to fully air dry
27. Apply alcohol-free skin protectant film to all skin under adhesive dressing materials to the edge of the dressing, avoiding the catheter exit site (Key-Site) and allow to fully air dry

Clinical practice point: skin is sticky when still wet

28. Broken skin or fragile/frail skin: cover with silicone adhesive dressing material or use alcohol-free skin protectant swab stick specific for broken skin

Clinical practice point: cut to shape with sterile scissors if required for small areas of skin impairment or leave uncut for extensive skin impairment

Securement

29. Securement:

Adhesive ESD	Tissue adhesive
© K Curtis 2021	© T Kleidon 2021
Attach adhesive ESD to the anchoring hub on the catheter and then adhere to skin (if being used)	With consultation of expert CVAD nurse consultant: consider application of tissue adhesive to insertion site and allow to air dry
Subcutaneous ESD: remains in situ from insertion to removal, not replaced at every dressing

Infection prevention

30. Apply antimicrobial disc, e.g. chlorhexidine gluconate (CHG), polyhexamethylene biguanide (PHMB) or silver alginate at the insertion site according to local policy:
    1. ensure disc has 360^o contact with the skin around exit site (Key-Site)
    2. position split at 5 or 7 o’clock

Clinical Practice Point: not all brands have writing on top of CHG discs 

Or place gel pad (incorporated in dressing material) over exit site (Key-Site)

CHG disc surrounding PICC exit site. Split is located at 5 o’clock (arrow).		CHG gel pad covering PICC exit site and first part of catheter
© K Curtis 2021		© K Curtis 2021
© K Curtis 2021	© K Curtis 2021	© Evan Alexandrou 2021	© K Curtis 2021

Dressing application

31. Apply dressing to dry skin:
    1. lay dressing gently over skin and catheter, then smooth firmly from centre to edges and avoid stretching material to prevent skin creases
    2. ensure edges are adhered to skin and catheter exit site (Key-Site) is in centre of dressing

PICC: ensure anchor hub of catheter is covered by the dressing:

© K Curtis 2021

tc-CICC: reduce risk of tension at insertion site, e.g. loop catheter under dressing so catheter is covered to bifurcation in catheter or apply dressing with catheter exiting on side

Tunnelled cuffed centrally inserted central catheter – catheter looped under dressing	Tunnelled cuffed centrally inserted central catheter – catheter exiting on side
© K Curtis 2021	© K Curtis 2021

Needleless connector (NC) replacement

32. Using non-touch technique:
    1. prior to disconnection: clean end of catheter and area where catheter connects to NC for 30 seconds. Hold catheter with gauze soaked in 2% chlorhexidine gluconate and 70% isopropyl alcohol with excess squeezed out and vigorously scrub with another piece of gauze soaked in same solution
    2. allow to fully air dry
    3. ensure clamp is closed (non-valved catheter)
    4. remove NC 
    5. clean catheter hub using a new gauze soaked in 2% chlorhexidine gluconate and 70% isopropyl alcohol with excess squeezed out for 30 seconds and allow to fully air dry
    6. attach new NC
33. Flush with 0.9% sodium chloride using a pulsatile technique and complete with the appropriate clamp disconnection technique for the type of needleless connector:

Type of needleless connector	Completion of flushing technique
Negative	clamp PRIOR to finishing flush and disconnecting the syringe
Positive	clamp AFTER finishing flush and disconnecting the syringe
Neutral	no specific clamping sequence required
Anti-reflux	no specific clamping sequence required

34. Repeat for each lumen
35. If securement strip over catheter (from step 13.b) is still in situ, remove at this stage.
36. Date the dressing strip and place on edge of dressing

Procedure completion and documentation

37. Discard waste and clean trolley as per institutional policy
38. Remove PPE and discard
39. Perform hand hygiene opens in a new tab or window
40. Document in the medical record:
    1. condition of the CVAD dressing
    2. skin condition at catheter exit site (Key-Site)
    3. skin condition under the dressing
    4. external catheter length
    5. securement and dressing material
    6. patency and functionality
    7. next dressing: inpatients, ambulatory or visiting nurse appointment.

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Version 7

Date	Summary of changes
19/07/2021	Reviewed and updated in tandem with eviQ education CVAD module review. Terminology updated throughout to reflect current evidence base, national and international guidelines. Aseptic Non touch Technique (ANTT®) information and terminology incorporated. Links to CVAD modules added. Images updated and added relevant to content. Sections updated as follows: Equipment updated. Procedure information updated and present in following distinct sections:  Removal of dressing materials, Measurement, Skin antisepsis, Skin protection, Securement, Infection prevention, Dressing application, Needleless connector replacement and Procedure completion and documentation. Links added to new resources - Skin Management Algorithm and CVAD assessment and documentation tool. Content updated to reflect current evidence and guidelines. References section added. Version number increased to V.7. Next review in 2 years.
02/02/2022	Minor updates to procedure order and some wording.
30/11/2023	Clinical procedure reviewed and updated in tandem with eviQ Education CVAD modules.  Skin antisepsis process updated to include using clean and sterile swab sticks. Next review 2 years.
24/01/2024	Equipment list updated to include antimicrobial disc or gel pad.

Version 6

Date	Summary of changes
30/10/2019	Reviewed electronically by Nursing Reference Committee. Minor changes to procedure to align with other clinical resources. Links updated. Next review 2 years.

Version 5

Date	Summary of changes
12/07/2011	Reformatted to comply with point of care template. Rationale and references have been moved to the resource document that is linked from this procedure.
14/02/2012	Information updated in line with NSW Health Policy Directive CVAD insertion and post insertion care 22/9/2011.
22/07/2013	Reviewed and updated to include needless injection cap change.
27/02/2015	Reviewed and updated.
31/05/2017	Transferred to new eviQ website. Version change to V.5.