Care of Sharps & Cannulation Guidance for Frontline Staff
Foreword 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. This act relates to sharps and its aim is to reduce sharps injuries which accounted for 17% of injuries reported since 1996. 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. 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.
My grateful thanks to Ben Hennessy, Karen Skillicorn-Aston and Heather Knight for their invaluable help in the production of this ebooklet.
Phil Convery Infection Control Lead South Central Ambulance Service NHSFT.
Care of Sharps & Cannulation Guidance Welcome to the first SCAS ‘E Booklet’ on the care of sharps, including 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:-
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The European Union Directives that govern the use of sharps
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Correct disposal of sharps Your legal and statutory responsibilities relating to the reporting of sharps incidents
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Cannula selection
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Peripheral cannula complications
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Aseptic Non Touch Technique (ANTT)
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Hand Hygiene Procedures
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Needles Thoracentisis Techniques and 12g
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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.
European Sharps Directives and Actions Directive Avoid use of sharps so far as is reasonably practicable Use safer sharps so far as is reasonably practicable Do not re 窶田ap needles after use Written instructions must be available explaining safe use & disposal of sharps Clearly marked and secure disposal containers must be used Disposal containers must be close to areas where sharps are being used Incidents involving sharps must be reported as soon as practicable Sufficient information explaining the circumstances of the incident must be provided SCAS must investigate incidents and take necessary actions to prevent recurrences SCAS must ensure that any treatment advised by a medical practitioner, including Post Exposure Prophylaxis (PEP) is made available to the employee SCAS must consider providing the employee with counselling
Action Use blunt tip needles for drawing up drugs / fluids. Only use SCAS provided safety cannulas. Ensure razors are protected by covers. Use retractable needle BM lancets. Ensure comprehensive training in handling of all sharps Needles should not be re-capped following use due to the risk of sharp injury. See SCAS Infection Prevention, Control and Decontamination policy SCAS provides yellow sharps bins throughout the Trust with temporary closure and anti-spill safety elements. Sharps bins are placed on all vehicles and in the main response bag that is taken to the patient. Inform the Occupational Health provider (during office hours), 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. 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. See SCAS Infection Prevention, Control and Decontamination policy and the Adverse Incident Reporting and Investigation policy. 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. PPC counselling is available through Occupational Health and TRIM may be considered if appropriate. (European Biosafety Network, 2010)
Correct Disposal of Sharps •
It is the Clinician’s responsibility to dispose of sharps; they must not be passed to anyone else for disposal.
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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.
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Never re-sheath a sharp as this carries a high risk of sharps injury
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Sharps must be inserted fully in to an approved container immediately after use
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If a needle is attached to a syringe dispose of as one and do not attempt to separate
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Never put your fingers inside a sharps container
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Containers must not be over filled
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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.
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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 venepuncture attempt, the needle must always be completely separated from the plastic cannula prior to disposal in an approved sharps container.
Reporting Sharps Incidents In the event of an accidental inoculation with a used needle or other sharp instrument, the following procedure must be followed:•
Immediately inform the SCAS Occupational Health Provider (if during office hours), the EOC duty manager and the duty Operations Manager or duty Team Leader
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Thoroughly wash the wound will plenty of water if water is not available use alcohol gel or wipes
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Make the wound bleed to remove and reduce contaminants
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Cover the wound with a plaster
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Wherever possible identify and make a note of the name of the patient involved and a good history of the incident
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Report for assessment as soon as possible to the SCAS Occupational Health provider or if out of hours report instead to your nearest Emergency Department remove or the
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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
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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: • • • • • •
An emergency course of Hep B vaccinations A Hep b booster Immunoglobulin administration A tetanus vaccination Retesting of blood for pathogens in 3 months time Counseling
Cannula Size Selection 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: -
Gauge Sizes and average flow rates (using water) Gauge
Flow Rate (ml/min)
Recommendations Emergency rapid infusion of viscous fluids or blood
14G
350
16G
215
As above
18G
104
Blood transfusions, parenteral nutrition, large volumes of fluids
20G
62
Blood transfusions, large volumes of fluids
22G
35
24G
24
Blood transfusions, most medications and fluids Medications, short term fluid administration, fragile friable veins and children (Adapted from: Royal Marsden Manual of Nursing Procedures, 2009)
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 cannualtions are: • • • • • • • • • •
Cannula embolism Damage to adjacent nerves Arterial puncture Catheter fracture and embolism Phlebitis – Inflammation of the vein Thrombo-embolism Local infection Haematoma formation Needle stick injury Extravasation – Infused fluid enters the subcutaneous tissues
Should you observe or suspect any of the complications listed, 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. Problem The vein is missed on insertion due to:
Prevention
Management
• Ensure good position and lighting. • Ensure better preparation and concentration. • Use good technique and accurate vein selection.
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Locate valves before insertion and insert just above the valve.
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• Venospasm • Bevel of the needle up against a valve • Penetration of the posterior vein wall by the device. • Possible vein collapse
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Use a good angle of approach that levels off after insertion in to the vein to prevent penetration of posterior wall.
Unable to advance the cannula due to:
• Ensure the cannula is released from the stylet before insertion • Ensure that a sufficient length of the cannula is inserted into the vein • before stylet is withdrawal • Ensure tourniquet remains sufficiently tight until insertion is completed. • Use good technique • Avoid valves where possible
• Inadequate anchoring • Collapsed vein • Incorrect position of nurse or patient • Inadequate palpation • Poor vein choice • Lack of concentration • Incorrect insertion angle.
Blood stops flowing through the device due to:
• Removing the stylet too far, leaving the cannula, no longer rigid enough • Encountering a valve • Not releasing the cannula from the needle before insertion • Poor anchoring or stretching of the skin. • Releasing the tourniquet too soon causing the vein to collapse. Difficulty in flushing the cannula it is in situ due to: • Cannula tip is up against a valve. • Cannula has pierced the posterior wall of the vein. • Cannula tip is resting on the wall of the vein. • There is an occlusion.
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Avoid areas along the vein where there may be valves Ensure careful insertion to prevent puncturing the posterior wall of the vein
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Withdraw the needle and correct the angle of insertion, checking the patient is not in pain. If unsuccessful or the patient sis in pain, remove the needle and if possible seek help from a colleague with more experience. Release and tighten the tourniquet. Gently stroke the vein above the needle to relieve venous spasm. Withdraw the needle slightly to move the bevel away from the valve. If the vein wall is penetrated, remove the device.
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. Tighten the tourniquet and wait for the vein to refill.
Withdraw the cannula slightly to move it away from the vein wall or valve and attempt to flush. If the vein wall is pierced, remove the cannula. Attempt to withdraw the clot and clear the occlusion.
(Adapted from Dougherty L, 2008)
Aseptic Non Touch Technique (ANTT) 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.
(Truman College, 2001)
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 cannualtion 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 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:•
Hot water or alcohol gel for hand washing
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Clean gloves
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A disposable tourniquet Sharps bin
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A sterile cannula of appropriate size
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A Chloroprep wipe
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Sterile gauze Sterile Vecafix dressing
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Sterile saline flush
The procedure for ANTT is as follows: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
5.
Clean the site using the chloroprep ensuring that you let it fully dry before proceeding any further – If it is not dry, it is not aseptic. Do not repalpate the vein. If this is necessary the area will need to be cleaned again. Dispose of the chloroprep in your sharps bin.
6.
Prepare your cannula, vecafix and flush by removing them from the packaging and ensuring they do not come into contact with any unsterilised surfaces including your hands.
7.
Clean your hands with alcohol gel 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. 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)
Hand Hygiene Procedures 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: -
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Before and after each work shift
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After using the toilet
Before and after caring for a service user Prior to any ANTT procedure Before putting on, and after removing, protective clothing After handling potentially contaminated items such as clinical waste, used linen or medical equipment Before eating, drinking or handling food
Hand washing does not always require running hot water and soap 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.
(National Patient Safety Agency, 2008)
Needles Thoracentesis Technique 12g Cannulas 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 (Trauma.org, 2004) arrest. Reliable and Early Signs for Tension Pneumothorax: - Pleuritic chest pain , respiratory distress, tachypnoea, tachycardia, low SPo2, agitation, ipsilateral, hyperexpansion, hypomobility, hyperresonance, decreased breath sounds, + or minus crackles or wheeze Pre-Terminal signs include: - Reduced respiratory rate, hypotension, decreasing SPo2, decreasing level of consciousness 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. 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. 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 (Studyblue Inc. 2013) for more details.
EZ-IO Instructions Using Aseptic Non Touch Technique: 8.
Locate landmarks
9.
Clean insertion site
10. Insert EZ-IO Needle Set 11. Remove Stylet from catheter and attach primed EZ-Connect 12. Syringe flush IO with 10ml saline 13. Start infusion under pressure
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)
References European Biosafety Network. (2010) ‘Prevention of Sharps Injuries in the Hospital and Healthcare Sector’, [online] Available: http://europeanbiosafetynetwork.eu/EU%20Sharps%20Injuries%20ImplementatioI %20Guidance.pdf [accessed 19/6/13] South Central Ambulance Service(2012) ‘Infection prevention, control & decontamination policy’, [online] available: http://www.southcentralambulance.nhs.uk/_assets/documents/policies/clinical/cspp %202%20ipcd%20policy%20v4%20%20feb%202012.pdf [accessed 20/6/13] Macklin, D, Chernecky, C.C. (2004) Real World Nursing Survival Guide: IV Therapy, Saunders, Missouri MO
Royal Marsden Hospital Manual of Nursing Procedures (2009) chapter 45, [online e book] available: www.swims.nhs.uk [accessed 1/11/2010] Dougherty, L. (2008) ‘Peripheral Cannulation’, Nursing Standard, 22(52), 49-56 Truman College (2001) ‘Infection Control for Nursing Students’, [online], available: http://faculty.ccc.edu/tr-infectioncontrol/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] 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) Currie G.P, Alluri R, Christie, C.G et al. (2007) ‘Pneumothorax: An update’, Post Graduate Medicine Journal, 83, 461-465 Trauma.org (2004) ' Chest Trauma Pneumothorax - Tension', [online], available: http://www.trauma.org/archive/thoracic/CHESTtension.html [accessed 20/06/201]. StudyBlue Inc. (2013) ‘Trauma’ [online] available: http://www.studyblue.com/notes/note/n/trauma/deck/3188747 [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]