Community Nurse Referral Letter (PICC Care)

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UCL Hospitals is an NHS Foundation Trust incorporating the Eastman Dental Hospital, Elizabeth Garrett Anderson & Obstetric Hospital, The Heart Hospital, Hospital for Tropical Diseases, National Hospital for Neurology & Neurosurgery, The Royal London Homoeopathic Hospital and University College Hospital.

Community Nurse Referral Letter (PICC Care)

Dear Community Nurse

The following patient requires care for a PICC (Peripherally Inserted Central Catheter):

Name………..………….……….….DOB………..…...

Diagnosis………...…

Address……….….………

……….…

Tel……….……..………GP………..…..………..……….

Please visit as follows………

………

……….

………

……….

………

The PICC has been checked by X-Ray. If the line is pulled out by more than 5cm please inform

us. As a baseline please note that on discharge the measurement between hub and exit site was

as follows:

Page 1 of 7……continues overleaf

Name of nurse making the referral:

Name………Signature…………..………

Date………Ward……….Tel 0845 1555 000 Ext………….

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…continued. Please note

• We have recently stopped using hepsal for locking lines

• We have recently changed our exit site cleaning regime. We are now using Chloraprep



• Dressing change & flush are due weekly: instructions attached

• Blood tests: if required patient will be given blood forms with dates for when the tests are due.

Please take blood from the PICC and sent to your usual Path lab. Instructions attached.

• Print off your own copies of the attached information from our website at www.uclh.nhs.uk/cvc

Page 2 of 7……continues overleaf

For advice or to arrange teaching contact Central Venous Access Team Tel: 0845 1555 000 ext 77491. Email: centralvenousaccess@uclh.nhs.uk

A Note About Infection: Most patients on chemotherapy are immunocompromised and infections should be acted on immediately.

♦ If the patient experiences a rigor and/or pyrexia following flushing of the line, contact the hospital

urgently. Haematology pts: contact 0845 1555 000 Bleep 1154. Oncology Pts: contact 07947 959 020.

♦ If the exit site is inflamed or there is purulent exudate, please take a swab. If the patient is pyrexial,

contact the hospital urgently as above. If not, this can wait until the next working day. The site should be inspected daily while infection is suspected and use of Biopatch & Chloraprep should be suspended until the infection has resolved.

♦ Handwashing and a non-touch technique are vital: please follow attached instructions.

Tick PICC discharge checklist to be completed by nurse referring patient

Patient supplied with items in List A (see below). Subsequently supplied by community team. Patient supplied with enough items in List B (see below).

Patient / carer knows to collect items from List B each time they attend the hospital Copy of this referral to be faxed to you

Hard copy of this referral to be given to patient

Patient knows who to contact if they have a problem with their PICC

Signed………..Date………

List A

• Dressing pack x 2

• Transparent dressings x 2 • Steristrips x 2

• 10 ml syringes x 10 • Green needles x 10 • Clinell wipes x 10

• 1 box 0.9% saline 10mls (IV use) • Sharps bin

List B

• Chloraprep Sepp .67mls



• Statlock dressings

• Biopatch • Bionectors

• Large yellow bags x 2 for disposal of

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Flushing a PICC

Community nurse referral for PICC Care page 3 / 7

• Our PICCs are fitted with Bionectors rather than bungs. These are needle-free access ports. YOU

SHOULD NEVER STICK NEEDLES INTO them, and they need to be changed once a week.

• Please treat each lumen separately, using a different syringe for each lumen.

• Most of our PICCs do not have clamps because each lumen has a valve which keeps air from

entering when the Bionector is changed.

Routine Flushing: weekly for unused lumens.

1. Wash hands. Draw up saline into syringes.

2. Clean end of Bionector with 2% chlorhexidine swab. Rub vigorously for 30 seconds using different parts of the swab. 3. Allow to dry fully without becoming contaminated (OR if

Bionector change is due, remove Bionector, clean end of lumen with alcohol swab, allow to dry, apply new Bionector and proceed.) 4. Remove needle from saline syringe. Push the syringe into the

Bionector and twist clockwise. The syringe should now stay in place.

5. Flush the PICC using a brisk “push-pause” technique (ie pause after each ml: this creates turbulence in the line and helps clear any tiny debris). DO NOT FORCE THE FLUSH or you may split the PICC. If you meet resistance, STOP and contact the hospital for advice. Never use a smaller syringe to try to unblock the PICC.

6. Remove syringe by twisting anti-clockwise while flushing in the last ml of saline. Leave Bionector in place.

Equipment Needed

per lumen

• 10 mls 0.9% Saline IV • 10 ml syringe (no

smaller)

• Needle

• 2% Chlorhexidine in

alcohol swabs

• Sterile towel

• Spare Bionector if

change due

Taking blood from a PICC.

1. Access the PICC using aseptic technique as for flushing.

2. Withdraw & discard first 4mls of blood from PICC. (If it won’t bleed back try flushing the line first or ask patient to take deep breaths.)

3. Take the blood sample.

4. Flush immediately with 2 x 10mls 0.9% saline: turbulent push-pause flush.

Equipment Needed

As for routine flush (above) but add:

• two extra empty 10 ml syringes (or one extra syringe plus Vacutainer connector)

• 2 x 10ml syringes of saline and a

spare in case PICC needs flushing before it will bleed back.

If you are flushing off chemotherapy…

Chemotherapy can damage cells. Avoiding contact with chemotherapy is like avoiding radiation in an X-ray department. Repeated exposure can be harmful. This is why it must be handled with care.

• Always wear apron and gloves when handling lines,

bags and infusion devices containing Chemotherapy

• Disconnect the giving set from the PICC leaving the Bionector in place.

• Avoid dripping or splashing of the Chemotherapy. • Dispose of contaminated equipment carefully in a

double yellow bag including the empty infusion device, the syringe used to flush the line through and your gloves and apron

• The yellow bag can be brought back to the hospital by

the patient at his / her next visit for disposal by the chemotherapy nurses. In the meantime it should always be stored out of the reach of children.

• Always wash your hands on removing your gloves and

apron.

In the event of a spillage

Chemotherapy can cause irritation if it comes into direct contact with the skin. If for any reason this should happen, flush the affected area with plenty of water and a mild soap. If any burning or rash develops subsequently, seek medical advice

.

Further info: Print off your own copy at www.uclh.nhs.uk/cvc. Contact Nurse Specialists: Tel: 0845 1555 000 x77491. Email:centralvenousaccess@uclh.nhs.uk

Out of hours: Haematology patients contact 0845 1555 000 Bleep 1154. Oncology patients contact 07947 959 020.

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Chloraprep and

Biopatch

Community nurse referral for PICC Care page 4 / 7

Chloraprep Sepp .67mls



is a single-use sterile applicator containing a 2% solution of Chlorhexidine Gluconate and 70% Isopropyl Alcohol. It’s coverage area is 5cm x 8cm.

•

It works by penetrating the top 5 layers of the skin where most bacteria is found.

• At UCLH Cancer Services and Adolescent Cancer we are now using Chloraprep

   

for cleaning all our Central Venous Catheter exit sites including PICCs.

Can it be used for all patients?

• Patients must be aged 2 months and over.

•

Adverse reactions are very rare but can cause anaphylaxis. Do not use on patients with a history of hypersensitivity to Chlorhexidine

.

How should it be used?

• Pinchthe sides of the applicator once (in the middle of the ampoule)until you feel the inner ampoule break. The antiseptic solution will soak the sponge tip.

• Use a gentle repeated back-and-forth friction rub for 30 seconds and allow to dry

completely.

• Discard in clinical waste bag.

•

If there is loose blood or exudate around the exit site, clean this away using 0.9% saline before using Chloraprep.

Biopatch



is a disc-shaped foam dressing impregnated with Chlorhexidine Gluconate. Biopatch inhibits bacterial growth.

• At UCLH we are now using it on all our Central Venous Catheter exit sites

including PICCs (except for patients under the age of 16).

Can it be used for all patients?

• Patients must be aged 16 or over.

• Adverse reactions are very rare but can cause anaphylaxis. Do not use on patients with a history of

hypersensitivity to Chlorhexidine.

How is

Biopatch



applied?

• The Biopatch should be placed around the PICC exit site with the BLUE side up • The catheter should rest on top of the Biopatch near the radial slit.

• A IV-dedicated transparent dressing should then be applied. For patients unable to tolerate a

transparent dressing try a dry dressing (eg Mepore).

How often should it be changed?

• Change the Biopatch and the dressing every 7 days or sooner if the dressing becomes detached

the Biopatch is more than half discoloured with blood / exudates

the white edges of the Biopatch become visible around edges of blue disc

What if the exit site looks infected?

• If the exit site is visibly infected: STOP using Biopatch & Chloraprep

   

. Take a swab and contact the GP or hospital. Change dressing daily and clean with 0.9% saline until the infection is resolved.

Do

Chloraprep



&

Biopatch



need prescribing & can they be obtained in the Community?

• They do NOT need to be prescribed. They can be hard to obtain in the Community. Patients should be

sent home with a supply and should collect a few more each time they visit the hospital.

Further information: Print off your own copy of attached info at www.uclh.nhs.uk/cvc

Contact Nurse Specialists: Tel: 0845 1555 000 x77491. Email: centralvenousaccess@uclh.nhs.uk.

Out of hours: Haematology patients contact 0845 1555 000 Bleep 1154. Oncology patients contact 07947 959 020. Updated by Liz Simcock October 2009

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Changing a PICC Dressing

Community nurse referral for PICC Care page 5 / 7

Remove dressing

DO NOT pull on

PICC!

Prise off transparent

wings & remove

Statlock

Prepare skin using

skinprep pad

(in Statlock pack)

Apply

Biopatch

Remove steristrip

DO NOT pull on

PICC!

Squeeze Chloraprep

Sepp to soak

sponge

Apply Statlock

Curve PICC away

from elbow joint

Apply Steristrip

Gently remove

Biopatch

30 seconds friction

rub back & forth

(covers 5 x 8 cm)

Allow to dry

Clean hands again

Apply transparent

dressing

Clean hands & put

on non-sterile gloves

Remove Statlock

DO NOT pull on

PICC!

Attach new Statlock

dressing

DON’T pull on PICC!

Put on sterile gloves

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PICC Troubleshooting

Community nurse referral for PICC Care page 6 / 7

Patient is pyrexial (above 38

o

C) and / or experiences a rigor

:

• Contact the hospital urgently for advice. May need IV antibiotics.

Exit site looks infected (inflammation / exudate around exit site)

• If the patient is pyrexial see above.

• Take

a swab.

• Contact the hospital or GP. May need oral antibiotics.

• Stop using

Biopatch



until infection resolved.

• Daily dressing changes if exudate is present & clean with 0.9% saline.

Sore, swollen inflamed arm above the PICC insertion site –

• Contact the hospital. This might be a thrombosis.

PICC is blocked:

• Contact the Central Venous Access Team (see contact details below).

PICC will not bleed back:

• If you are just doing a routine flush don’t worry. If you need to administer iv

medications or take blood samples contact the Central Venous Access Team.

PICC has been pulled out by more than 5cm:

• Must be x-rayed before continuing with treatment. Contact the hospital.

PICC has been cut, split or damaged:

• Fold the line over on itself between the break and the patient and secure with tape.

This will prevent air entry. Contact the hospital. PICC may need to be removed (see

below) but note that PICCs can sometimes be repaired.

If the PICC needs to be removed

1. Check your manager is happy for you to remove PICC

2. Place PICC exit site below the level of the heart.

3. Remove the dressing.

4. Pull PICC out slowly an inch or two at a time.

5. If you meet resistance, STOP. Do not risk snapping the line.

6. Resistance may be due to venospasm. Wait 5 minutes before resuming.

Applying warm packs to the patient’s arm may help. If not, contact the hospital.

7. Once the PICC is out, apply pressure to the exit site with sterile gauze.

8. Apply air-proof dressing.

Equipment

• Non-sterile gloves • Gauze swabs

• Air-proof dressing

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