Skin preparation for vascular device insertion and lumbar puncture

This guideline details the best practice in preparing the patient's skin before undertaking the specified invasive procedures to minimise the risk of infection.

Introduction

This clinical guideline will outline the use of Chloraprep^® as a product to decontaminate the skin. Chloraprep^® is not licensed by the Medicines and Healthcare products Regulatory Agency (MHRA) for use on infants below the age of two months. The Trust evaluated the use of Chloraprep ^®  and concluded that Chloraprep ^®  will be used for skin decontamination prior to device insertion, on all children with intact skin (Rationale 1).

The guideline must be read in conjunction with the following Trust guidelines and policies:

• Hand hygiene
• Aseptic non touch technique guideline for intravenous therapy
• Safe disposal of sharps
• Central venous access devices
• Peripheral venous access devices
• Intraosseous Access
• Peripheral cannulation of children
  

This guideline should be used by all professionals who undertake and/or assist in the following procedures:

• access of indwelling devices such as Port-caths
• accessing fistulas
• insertion of peripheral cannulae
• taking peripheral blood cultures
• performing lumbar punctures
• inserting central venous devices such as PICC lines, CVC and Port-caths

For venepuncture (when no blood is obtained for culture), the skin will continue to be prepared with 70% alcohol wipes (eg Sterets^®)(Rationale 1).

Chloraprep^® will not be stored on any of the resuscitation trolleys within the Trust (Rationale 2).

Training

All HCP undertaking or assisting in the above procedures should be familiar with the product, the benefits of use and contraindications (Rationale 3).

Background

Evidence

Research states that 'approximately three in every 1,000 patients admitted to hospital in the UK acquire a bloodstream infection, and nearly one third of these infections are related to central venous access devices' (Pratt et al 2007). Bloodstream infections associated with the insertion and maintenance of central venous access devices (CVAD) are among the most dangerous complications of healthcare (Pratt et al 2007).

However, Maki et al reported in 2003 that both peripheral and central venous catheters are associated with a risk of catheter-related bloodstream infection (Maki et al 2003). It is therefore essential that a consistent and best practice approach in dealing with the pre-insertion insertion and maintenance of all vascular devices is established (Rationale 4).

The product solution recommended for decontamination of the skin site is alcoholic chlorhexidine gluconate using a single patient use application, preferably 2% chlorhexidine gluconate in 70% isopropyl alcohol (Pratt et al 2007). In order to reduce the risk of microbial colonisation and subsequent sepsis it is recommended that the skin should be disinfected for 30 seconds (RCN 2010) and be allowed to dry.

However, this can only be achieved if the health care professional observes standard precautions when carrying out procedures using appropriate hand decontamination and performing effective aseptic non touch technique (Hart 2007; Pratt et al 2007).

Contraindications

Always check patient for prior allergic reactions to the chosen product. The use of 2% chlorhexidine and 70% isopropyl alcohol should not be used on any patients that have a known or suspected sensitivity (Rationale 5). 

The current 2% chlorhexidine (CHG) and 70% isopropyl alcohol (IPA) device in the Trust is Chloraprep^®. This guideline explains this individual product and does not relate to any other 2% chlorhexidine and 70% isopropyl alcohol devices. Should the Trust change products this policy will become invalid (Rationale 6).

Chloraprep^® is a sterile single patient use plastic applicator with a gauze or sponge tip, containing a glass ampoule of cutaneous solution 2% CHG and 70% IPA. The volume of solution contained will vary according to the product size. 

All health professionals should be vigilant in completing and recording the visual infusion phlebitis (VIP) score and report any concerns to the appropriate medical team.

After use all Chloraprep^® devices should be disposed of in a sharps or WIVA bin (Rationale 8). 

How to use Chloraprep^®

To facilitate the appropriate use of Chloraprep^® and to decrease the potential for flooding the skin with solution, the following guidance should be adhered to (Rationale 9).

Sepp 0.67ml Peripheral cannulation and peripheral venepuncture for blood cultures.

Frepp 1.5ml Fistula cleaning, lumbar puncture (small patients), care and maintenance of indwelling CVADs, inserting central venous devices such as PICC lines, CVCs, Port-caths and IO needles.

3ml applicators Lumbar puncture (large patients).

Application of Chloraprep^® - over the age of two months

For further guidance on this application technique see Carefusion 2010.

• Prepare procedural tray as per aseptic non-touch technique (ANTT) guidelines.
• Check that applicator packet is sealed, intact and in date.
• Remove the applicator from the packet and hold it gauze or sponge side down. Ensure that the gauze or sponge area remains sterile prior to application on the patients skin.
• Activate the product by:
  • Firmly squeezing the Sepp^® applicator between your thumb and forefinger breaking the glass ampoule inside the device (you may need to use both hands to do this).
  • Firmly pinching the wings of the Frepp^® applicator breaking the glass ampoule inside.
• Gently press the gauze or sponge part of the applicator onto the patients skin, applying the solution in a back and forth motion for 30 seconds.
• Allow the covered area to dry naturally, this will take approximately 30 seconds.
• Carry out procedure. Should you need to re-palpate the skin, repeat the above procedure with a new applicator (Scales 2009)(Rationale 10).
• Upon completion of the procedure ensure that all waste is disposed of in accordance with trust policy. 

Application of Chloraprep^® - under the age of two months

• Prepare procedural tray as per ANTT guidelines.
• Check that applicator packet is sealed, intact and in date.
• Remove the applicator from the packet and hold it gauze or sponge side down. Ensure that the gauze or sponge area remains sterile prior to application on the patients skin
• Activate the product by:
  
  
  • Firmly squeezing the Sepp^® applicator between your thumb and forefinger breaking the glass ampoule inside the device (you may need to use both hands to do this).
  • Firmly pinching the wings of the Frepp^® applicator breaking the glass ampoule inside.
• Gently press the gauze or sponge part of the applicator onto the patients skin, applying the solution in a dabbing motion for 30 seconds.
• Allow the covered area to dry naturally, this will take approximately 30 seconds.
• Carry out procedure. Should you need to re-palpate the skin, repeat the above procedure (Scales 2009)(Rationale 10).
• Once procedure is completed, including the application of the dressing, any exposed skin previously cleaned with Chloraprep^® should be washed/wiped clean with sterile water.
• Upon completion of the procedure ensure that all waste is disposed of in accordance with trust policy.
  

NOTE: CHLORAPREP^® APPLICATORS ARE REQUIRED TO BE DISPOSED OF IN A SHARPS OR WIVA BIN.

Rationale

Rationale 1: As agreed by the Infection Control Committee November 2010 and will be subject to a six-month review by the committee.
Rationale 2: The Trust has acknowledged that at present the infection risk of taking a venepucture blood sample is low.
Rationale 3: During any procedures undertaken during an emergency, the 30-second clean and 30-second drying time cannot be guaranteed.
Rationale 4: This will ensure consistency of skin preparation, device insertion and maintenance of a device wherever the child is within the Trust.
Rationale 5: This will ensure that the skin is disinfected in a manor appropriate for the patient.
Rationale 6: This may cause further trauma to the patient's skin unnecessarily.
Rationale 7: Some products require different application techniques. Using the incorrect application method could adversely affect the effectiveness of the device used.
Rationale 8: The product contains glass vials that are broken on activation.
Rationale 9: As advised by manufacturer Carefusion.
Rationale 10: Skin contamination can occur as a result of repalpating the skin after cleansing. Therefore recleansing will be required to sufficiently decontaminate area (Scales 2009).

References

Reference 1:
Maki DG, Crnich CJ (2003) Line sepsis in the ICU: prevention, diagnosis, and management. Semin Respir Crit Care Med 24 (1): 23-36. 

Reference 2:
Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SR, McDougall C, Wilcox MH (2007) epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 65 Suppl 1: S1-64. 

Reference 3:
Scales K (2009) Correct use of chlorhexidine in intravenous practice. Nurs Stand 24 (8): 41-6. 

Reference 4:
Royal College of Nursing (2010) Standards for infusion therapy. Viewed on: 01/10/2010.

Reference 5:
Hart S (2007) Using an aseptic technique to reduce the risk of infection. Nurs Stand 21 (47): 43-8. 

Reference 6:
Carefusion (2010) Product Education and Useage Information Viewed on: 01/10/2010. 

Document control information

Ashley Nadine Hurford, Practice Educator, Cardiorespiratory Unit