South Central Ambulance Service NHS Foundation Trust
SAFER SHARPS CLINICAL MANAGEMENT AND HAND HYGIENE FOR ALL STAFF
On 11th May 2013, a new regulation became statute across the EU community. This regulation (2010/32/EU), has placed new responsibilities, not only on healthcare Trusts, but also on healthcare professionals.
There are references to other statutory procedures that will be of benefit to other staff such as the Board of Directors, PTS, EOC / 111 call centres, fleet and other operational staff and administrative personnel.
This act relates to sharps and its aim is to reduce sharps injuries which accounted for 17% of injuries reported since 1996.
My grateful thanks to Ben Hennessy, Karen Skillicorn-Aston and Heather Knight for their invaluable help in the production of this e-booklet.
FOREWORD
One of the processes is to ensure that those who use sharps are identified and have received the correct training and/or updates in their uses.
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Although the production of this e-booklet, looks at areas where sharps are in practice and aims to re-educate or refresh your knowledge of the processes and procedures that you, as the healthcare professional, need to know, and inform you of other areas of practice that link in with such procedures.
Phil Convery Infection Control Lead South Central Ambulance Service NHS Foundation Trust.
Care of sharps and cannulation guidance for frontline staff
This booklet is designed to be a ‘quick reference’ guide that can be used to remind you of the following: èè Hand Hygiene Procedures èè Aseptic Non Touch Technique (ANTT) èè The European Union Directives that govern the use of sharps èè Correct disposal of sharps èè Your legal and statutory responsibilities relating to the reporting of sharps incidents èè Cannula selection èè Peripheral cannula complications èè Needles Thoracentesis Techniques and 12g èè EZ-IO equipment and instructions This guide should be read in conjunction with the SCAS Infection Prevention, Control and Decontamination Policy which can be found on the staff intranet or on the trust website.
CARE OF SHARPS & CANNULATION GUIDANCE
Welcome to the SCAS ‘e-booklet’ on the care of sharps, including cannulation guidance for frontline staff.
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HAND HYGIENE PROCEDURES 4
Hand washing is widely acknowledged to be the single most important activity for reducing the spread of infection from one person to another. To minimise this risk hands must be regularly washed throughout the day, especially: èè Before and after each work shift èè Before and after caring for a service user èè Prior to any ANTT procedure èè Before putting on, and after removing, protective clothing èè After handling potentially contaminated items such as clinical waste, used linen or medical equipment èè After using the toilet èè Before eating, drinking or handling food Hand washing does not always require soap and water although this should be used if available. In the pre-hospital environment use of hand sanitizer is acceptable and the same six step technique should be applied to either device.
Care of sharps and cannulation guidance for frontline staff
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All Clinicians who practice invasive procedures are at the ‘frontline’ of defences against the chain of infection. Our best defence against it when practicing cannulation is to use ANTT – Aseptic Non Touch Technique. Infectious agent
ASEPTIC NON TOUCH TECHNIQUE (ANTT)
Susceptible Host
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Reservoir
CHAIN OF INFECTION Portal of Entry
Portal of Exit Mode of Transmission
Transmission of infection occurs when an infectious agent leaves its reservoir or host through a portal of exit and is conveyed through a mode of transmission through a portal of entry into a susceptible host. The reservoir in the case of infection through a non-aseptic cannulation is YOU. The infectious agent is any bacteria, virus or fungi you are carrying and the portal of exit is YOUR SKIN or dirty gloves.
The mode of transmission is TOUCH and the portal of entry is the cannulation site or cannula itself. By removing the portal of exit and the mode of transmission for the infectious agent from the reservoir you effectively break the chain of infection and prevent your patient from becoming a susceptible host. Full aseptic technique is not possible in the prehospital environment but ANTT is the next best alternative and is accepted best practice. Equipment required for ANTT is as follows: èè Soap and water or alcohol gel or foam for hand sanitizing èè Clean gloves èè A disposable tourniquet èè Sharps bin èè A sterile cannula of appropriate size èè Chloraprep èè Sterile gauze èè Sterile Vecafix dressing èè Sterile saline flush
Care of sharps and cannulation guidance for frontline staff
1. Ensure your patient understands the procedure you are about to carry out and gain informed consent 2. Ensure all the equipment you require is within easy reach and placed on a sterile surface. Surfaces can be sterilised with the use of a Clinell wipe 3. Apply a single use tourniquet to the patients arm taking in to consideration, pain, injury, fistulas, lymphedema and pPCI protocols Select a cannula site by palpation 4. Clean your hands with alcohol gel/foam. 5. Clean the site using the chloraprep ensuring that you let it fully dry before proceeding any further – If it is not dry, it is not aseptic. Do not re-palpate the vein. If this is necessary the area will need to be cleaned again. Dispose of the chloraprep in your sharps bin. 6. Prepare your cannula, vecafix and flush by removing them from the packaging and ensuring they do not come into direct contact with any unsterilized surfaces including your hands.
7. Clean your hands with alcohol gel or foam a second time and don clean gloves. 8. Open the wings of the cannula and enter the vein at approximately 30o to the skin. Ensure the skin is stretched using your other hand to fixate the vein. 9. Advance until you see a good flashback into the chamber of the cannula and advance the cannula whilst withdrawing the needle. Occlude the vein and fully remove the needle, disposing of it immediately in the sharps bin and cap your cannula. Should excess bleeding occur, use the sterile gauze to clean the area. 10. In failed cannulas, occlude the cannula to prevent bleeding and fully retract the needle from cannula body prior to disposal in an approved container. The needle must not be left inside the cannula when disposed as this is an unsafe practice. 11. Secure the cannula using a vecafix dressing ensuring the insertion site is visible for inspection, and cannulas placed using a full ANTT should be labelled with date and time. At handover the nurse must be immediately informed if ANTT could not be used.
ASEPTIC NON TOUCH TECHNIQUE (ANTT)
The procedure for ANTT is as follows:-
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NEEDLES THORACENTESIS TECHNIQUE 12G CANNULAS 8
12. Flush your cannula using the sterile saline flush 13. Reassure your patient and dispose of any waste including your gloves and wash your hands. (This guidance was adapted for application within SCAS from an original video by West Midlands Ambulance Service, 2013)
Care of sharps and cannulation guidance for frontline staff
DIRECTIVE
ACTION
Avoid use of sharps so far as is reasonably practicable
Use blunt tip needles for drawing up drugs / fluids.
Use safer sharps so far as is reasonably practicable
Only use SCAS provided safety cannulas.
Sufficient information explaining the circumstances of the incident must be provided
Ensure razors are protected by covers.
Needles should not be re-capped following use due to the risk of sharp injury.
Ensure care is taken when reporting. See SCAS Infection Prevention, Control and Decontamination policy and the Adverse Incident Reporting and Investigation policy for more details.
Use retractable needle BM lancets.
See SCAS Infection Prevention, Control and Decontamination policy
SCAS must investigate incidents and take necessary actions to prevent recurrences
See SCAS Infection Prevention, Control and Decontamination policy and the Adverse Incident Reporting and Investigation policy.
Ensure comprehensive training in handling of all sharps
SCAS provides yellow sharps bins throughout the Trust with temporary closure and anti-spill safety elements.
Disposal containers must be close to areas where sharps are being used
Sharps bins are placed on all vehicles and in the main response bag that is taken to the patient.
SCAS must ensure that any treatment advised by a medical practitioner, including Post Exposure Prophylaxis (PEP) is made available to the employee
Incidents involving sharps must be reported as soon as practicable
Inform the Occupational Health provider, the duty TL and EOC Duty Manager as soon as possible, and then use the Datix reporting process. See SCAS Infection Prevention, Control and Decontamination policy and the Adverse Incident Reporting and Investigation policy for more details.
Attending the SCAS Occupation Health provider during office hours or an Emergency Department if out of hours, forms part of the sharps procedures in the SCAS Infection Prevention, Control and Decontamination policy. PEP is prescribed by the assessing physician and offered at their discretion.
SCAS must consider providing the employee with counselling
PPC counselling is available through Occupational Health and TRIM may be considered if appropriate.
EUROPEAN SHARPS DIRECTIVES AND ACTIONS
ACTION
DIRECTIVE
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CORRECT DISPOSAL OF SHARPS 10
èè It is the Clinician’s responsibility to dispose of sharps; they must not be passed to anyone else for disposal èè It is the Clinician’s responsibility to ensure that an approved sharps disposal container is in easy reach prior to the use of a sharp - Sharps must not be carried about unnecessarily èè Never re-sheath a sharp as this carries a high risk of sharps injury èè Sharps must be inserted fully in to an approved container immediately after use èè If a needle is attached to a syringe dispose of as one and do not attempt to separate èè Never put your fingers inside a sharps container èè Containers must not be over filled èè Sharps containers must be sealed and labeled when the contents reach the ‘fill line’, damage or leaking or after an invasive procedure on a known infectious patient. èè Sharps container must be disposed of in line with local protocol. (South Central Ambulance Service, 2012)
SCAS provide safety cannulas to try and reduce the risk of sharps injury to all staff and service users and only safety cannulas may be used. However the safety function only becomes active when the needle is fully retracted and removed from the plastic cannula. This means that when disposing of cannulas following an unsuccessfully venipuncture attempt, the needle must always be completely separated from the plastic cannula prior to disposal in an approved sharps container.
Care of sharps and cannulation guidance for frontline staff
èè Immediately inform the SCAS Occupational Health Provider (if during office hours), the EOC duty manager and the duty Operations Manager or duty Team Leader èè Thoroughly wash the wound will plenty of water if water is not available use alcohol gel or wipes èè Make the wound bleed to remove and reduce contaminants èè Cover the wound with a plaster èè Wherever possible identify and make a note of the name of the patient involved and a good history of the incident èè Occupation Health risk assessments can be completed over the phone (01327 810269 office hours or 0800 413324 outside of these). In most cases it will be appropriate to report to your nearest Emergency department for a risk assessment. èè The duty manager should inform the occupational health provider on your behalf of the incident as soon as practicable if it occurs out of hours, to ensure any relevant follow up is received and due consideration is given to both your physical and emotional needs
èè In accordance with the SCAS Accident/ Incident reporting policy a Datix report must be completed and appropriately investigated (South Central Ambulance Service, 2012). The treatment you receive will depend on the type of incident. Assessment may include checking your hepatitis B status through your medical record and by taking a blood sample to look for Hep B antibodies. Blood will also be checked for other pathogens including HIV. Blood may also be stored for checking in 3 months’ time. Treatment you receive may include: èè An emergency course of Hepatitis B (HBV) vaccinations èè An HBV booster èè Immunoglobulin administration èè Retesting of blood for pathogens in 3 months’ time èè Counseling
REPORTING SHARPS INCIDENTS
In the event of an accidental inoculation with a used needle or other sharp instrument, the following procedure must be followed:
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Gauge Sizes and average flow rates (using water)
CANNULA SIZE SELECTION
Gauge Flow Rate Recommendations (ml/min)
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14G 16G
Research has demonstrated that the incidence of vascular complications increases as the ratio of external diameter to vessel lumen increases. (Macklin, 2004) Therefore Clinicians should always use the smallest size cannula that will provide effective treatment for each intervention. Routine use of large bore cannulas without justification also inflicts unnecessary pain and suffering upon your patient. Please see the table below for clarification:
350
Emergency rapid infusion of viscous fluids or blood
215
As above
104
Blood transfusions, parenteral nutrition, large volumes of fluids
62
Blood transfusions, large volumes of fluids
35
Blood transfusions, most medications and fluids
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Medications, short term fluid administration, fragile friable veins and children
18G 20G 22G 24G
(Adapted from: Royal Marsden Manual of Nursing Procedures, 2009)
Care of sharps and cannulation guidance for frontline staff
èè Cannula embolism èè Damage to adjacent nerves èè Arterial puncture èè Catheter fracture and embolism èè Phlebitis – Inflammation of the vein èè Thrombo-embolism èè Local infection èè Haematoma formation èè Needle stick injury èè Extravasation – Infused fluid enters the subcutaneous tissues
PERIPHERAL CANNULA COMPLICATIONS Should you observe or suspect any of the complications listed, remove and dispose of cannula and using a new one re-site your cannula, document carefully and ensure that you advise the nurse at handover so that treatment of symptoms and antibiotics can be considered if required.
PERIPHERAL CANNULA COMPLICATIONS
Peripheral cannulation is an invasive procedure and can be subject to complications, it should only performed when the condition of the patient warrants immediate access and infusion of fluids or a bolus of medication OR there is a significant and overwhelming risk of patient deterioration. The complications of peripheral cannulations are:
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PERIPHERAL CANNULA COMPLICATIONS
PROBLEM
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PREVENTION
The vein is missed on insertion due èè Ensure good position and to: lighting. èè Ensure better preparation èè Inadequate anchoring and concentration. èè Collapsed vein èè Use good technique and èè Incorrect position of nurse or accurate vein selection. patient èè Inadequate palpation èè Poor vein choice èè Lack of concentration èè Incorrect insertion angle. Blood stops flowing through the device due to: èè Venospasm èè Bevel of the needle up against a valve èè Penetration of the posterior vein wall by the device. èè Possible vein collapse
MANAGEMENT èè Withdraw the needle, dispose and use clean. Correct the angle of insertion, checking the patient is not in pain. èè If unsuccessful or the patient is in pain, remove the needle and if possible seek help from a colleague with more experience.
èè Locate valves before insertion èè Release and tighten the tourniquet. and insert just above the èè Gently stroke the vein above valve. the needle to relieve venous èè Use a good angle of approach that levels off spasm. after insertion in to the vein èè Withdraw the needle slightly to prevent penetration of to move the bevel away from the valve. posterior wall. èè If the vein wall is penetrated, remove the device.
Care of sharps and cannulation guidance for frontline staff
PREVENTION
Unable to advance the cannula due to: èè èè èè èè èè
èè Ensure the cannula is released from the stylet before insertion èè Ensure that a sufficient Removing the stylet too far, length of the cannula is leaving the cannula, no longer inserted into the vein rigid enough èè before stylet is withdrawal Encountering a valve èè Ensure tourniquet remains Not releasing the cannula from sufficiently tight until the needle before insertion insertion is completed. Poor anchoring or stretching of èè Use good technique the skin. Releasing the tourniquet too soon èè Avoid valves where possible causing the vein to collapse.
Difficulty in flushing the cannula that is in situ due to: èè èè èè èè
èè Avoid areas along the vein where there may be valves èè Ensure careful insertion Cannula tip is up against a valve. to prevent puncturing the Cannula has pierced the posterior posterior wall of the vein wall of the vein. Cannula tip is resting on the wall of the vein. There is an occlusion.
MANAGEMENT èè In the event of early stylet removal or encountering a valve, connect a syringe of 0.9% sodium chloride, flush the cannula and advance at the same time in an effort to ‘float’ the device into the vein. èè Tighten the tourniquet and wait for the vein to refill.
èè Withdraw the cannula slightly to move it away from the vein wall or valve and attempt to flush. èè If the vein wall is pierced, remove the cannula. èè Attempt to withdraw the clot and clear the occlusion.
PERIPHERAL CANNULA COMPLICATIONS
PROBLEM
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NEEDLES THORACENTESIS TECHNIQUE 12G CANNULAS 16
Tension pneumothorax is the progressive build-up of air within the pleural space, usually due to a lung laceration. Progressive build-up of pressure in the pleural space pushes the mediastinum to the opposite hemithorax, and obstructs venous return to the heart. This leads to circulatory instability and may result in traumatic arrest. (Trauma.org, 2004) èè Reliable and Early Signs for Tension Pneumothorax: Pleuritic chest pain, respiratory distress, tachypnea, tachycardia, low SPo2, agitation, ipsilateral, hyperexpansion, hypomobility, hyperresonance, decreased breath sounds, + or minus crackles or wheeze. èè Pre-Terminal signs include: Reduced respiratory rate, hypotension, decreasing SPo2, decreasing level of consciousness èè Inconsistent and unreliable signs: - Tracheal deviation, distended neck veins (Bethel J, 2008) (British Medical Journal, 2012) (Currie G.P et al, 2007)
Pre-hospital management of tension pneumothorax is chest decompression using the following needle thoracentesis technique. Using Aseptic Non Touch Technique: 1. Prepare a 14g cannula by attaching a 5ml syringe to it 2. Locate landmarks - the second rib space in the mid-clavicular line just above the top of the third rib 3. Clean insertion site 4. At an angle of 90o to the patient’s chest insert a 14g intravenous cannula 5. Advance the needle until air can be aspirated into a syringe connected to the needle. 6. Withdraw the needle and dispose of as the sharps disposal procedure outlined earlier in this guidance, leaving the cannula in situ and open to air. An immediate rush of air out of the chest confirms the presence of a tension pneumothorax. 7. Secure the cannula with a vecafix or tape to prevent unwanted removal from the chest wall.
Care of sharps and cannulation guidance for frontline staff
It is important to note however that these 12g cannulas are non-safety needles meaning that a sheath does not deploy when the needle is removed from the cannula. This means extra care must be taken when handling and disposing of this device. Please refer to the ‘Correct Disposal of Sharps’ section of this booklet for more details.
NEEDLES THORACENTESIS TECHNIQUE 12G CANNULAS
SCAS has identified that in bariatric patients, a standard 14g safety cannula may not be of sufficient length to pass through the chest wall and enter the pleural space effectively. To minimise this clinical risk SCAS is procuring larger 12g cannulas. These needles have a larger bore but are crucially approximately ½” longer in length.
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Using Aseptic Non Touch Technique: Locate landmarks Clean insertion site Insert EZ-IO Needle Set Remove Stylet from catheter and attach primed EZ-Connect 5. Syringe flush IO with 10ml saline 6. Start infusion under pressure
EZ-IO INSTRUCTIONS
1. 2. 3. 4.
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Needle sizes Pink (15mm) - For use in patients weighing 3-39 kilograms, and for patients with minimal tissue over insertion sites. Blue (25 mm) - For any patient weighing more than 39 kilograms, or for patients who have too much tissue over the insertion site for the 15 mm Needle Set to be used. Yellow (45 mm) - For patients weighing more than 39 kilograms who have excessive tissue over the targeted insertion site.
(Vidacare, 2013)
Care of sharps and cannulation guidance for frontline staff
South Central Ambulance Service (2013) ‘Infection Prevention, Control & Decontamination policy’, [online] available: http://www.southcentralambulance.nhs. uk/_assets/documents/policies/clinical/cspp%202%20 ipcd%20policy%20v4%20%20feb%202012.pdf [accessed 20/6/13]
National Patient Safety Agency. (2008) ‘Clean Hands Save Lives Hand Cleaning Techniques’ [online], available: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59848 [accessed 20/6/13] Bethel, J. (2008) ‘Tension Pneumothorax’, Emergency Nurse, 16(4), 26-29 British Medical Journal e learning module. (2012) ‘Tension Pneumothorax: Diagnosis and management in association with the EMJ’ (available via Athens)
Macklin, D, Chernecky, C.C. (2004) Real World Nursing Survival Guide: IV Therapy, Saunders, Missouri MO
Currie G.P, Alluri R, Christie, C.G et al. (2007) ‘Pneumothorax: An update’, Post Graduate Medicine Journal, 83, 461-465
Royal Marsden Hospital Manual of Nursing Procedures (2009) chapter 45, [online e book] available: www.swims. nhs.uk [accessed 1/11/2010]
Trauma.org (2004) ‘ Chest Trauma Pneumothorax Tension’, [online], available: http://www.trauma.org/ archive/thoracic/CHESTtension.html [accessed 20/06/201].
Dougherty, L. (2008) ‘Peripheral Cannulation’, Nursing Standard, 22(52), 49-56
StudyBlue Inc. (2013) ‘Trauma’ [online] available: http:// www.studyblue.com/notes/note/n/trauma/deck/3188747 [accessed 20/6/13]
Truman College (2001) ‘Infection Control for Nursing Students’, [online], available: http://faculty.ccc.edu/trinfectioncontrol/chain.htm [accessed 20/6/13] West Midlands Ambulance Service (2013) ‘Ambulance IP&C –Part 3 – Aseptic No Touch Technique’ (video), [online video], available: http://www.youtube.com/ watch?v=Tn3tfTAoog8 [accessed 20/6/13]
Vidacare. (2013) ‘EZ-IO Insertion and removal instructions’, [online], available: http://www.vidacare. com/EZ-IO/Index.aspx [accessed 20/6/13]
REFERENCES
European Biosafety Network. (2010) ‘Prevention of Sharps Injuries in the Hospital and Healthcare Sector’, [online] Available: http://europeanbiosafetynetwork.eu/EU%20Sharps%20 Injuries%20ImplementatioI%20Guidance.pdf [accessed 19/6/13]
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