Skin preparation for the insertion of vascular access devices

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

This guideline no longer includes skin preparation for lumbar puncture. For information about skin preparation for lumbar punctures, see Intrathecal Cytotoxic Chemotherapy: administration via a lumbar puncture or Ommaya reservoir guideline.

Introduction

This clinical guideline outlines the use of Chloraprep® as a product to decontaminate the skin. Chloraprep® is a licensed single use product available within the Trust and contains 2% Chlorhexidine and 70% isopropyl alcohol.  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 recognises the MHRA’s position and has concluded that the use of Chloraprep® will be used for skin decontamination prior to device insertion, on all children with intact skin including those below 32 weeks gestation and less than two weeks of life (Rationale 1).  Although strict adherence to the use of Chloraprep® is recommended in all cases, any complications associated with its application should be reported through the Trusts incident reporting system, DATIX. 

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

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

  • Insertion of peripheral cannulae 
  • Insertion of central venous devices such as PICC lines, CVL,  implantable access Port 
  • Insertion of Intraosseous device – Non clinical emergency

For venepuncture (when no blood is obtained for culture), the skin will continue to be prepared with 70% alcohol wipes (eg Sterets®) (Rationale 2).

To access venous access devices, fistula etc. refer to the Central Venous Access Devices (long term) and Central Venous Access Devices (extracorporeal therapies) Guidelines

The Trust does not store Chloraprep® on any of the resuscitation trolleys (Rationale 3).  

Training

All staff undertaking or assisting in the above procedures should be familiar with the product, the benefits of use and contraindications.  Adherence to this guideline should be maintained at all times to prevent inappropriate pooling of the solution on the skin of the patient (Rationale 4).

Background

Evidence

Health care associated infections (HCAI) pose a significant threat to patient safety (Loveday et al 2014).  Pratt et al (2007) state 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'. 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).  Maki and Crnich published evidence, that both peripheral and central venous catheters are associated with a risk of catheter-related bloodstream infections (Maki and Crnich 2003). With advancing paediatric healthcare the use of invasive devices is necessary part of clinical practice and as such the risk of developing a device related infection is increased (Chesshyre et al 2015

The solution recommended for decontamination of the skin site, before vascular device insertion is alcoholic chlorhexidine gluconate, using a single patient use application, 2% chlorhexidine gluconate in 70% isopropyl alcohol has been suggested as the preferred concentration of product (Pratt et al 2007, Loveday et al 2014). Evidence has been published suggesting that in order to reduce the risk of microbial colonisation and subsequent sepsis it is recommended that the skin should be disinfected for 30 seconds and be allowed to dry (Carefusion 2010a, 2010b, Royal College of Nursing (RCN) 2010). The Trust recommends that this is for a minimum of  30 seconds (Rational 5). 

Critically ill children are susceptible to blood stream infections (Harron et al 2014).  Therefore it is essential that a consistent and best practice approach in dealing with the pre-insertion insertion and maintenance of all vascular devices is established (European Medicines Agency 2014). The use of Chloraprep® alone, will not reduce infection rates, a package of standardised care is required. Standardisation, can only be achieved if the health care professional performs all  precautions required when carrying out a procedure, this includes using appropriate hand decontamination and performing effective aseptic non touch technique (Hart 2007; Pratt et al 2007, Loveday et al 2014). 

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 6).  Chloraprep® cannot be used on broken skin, the health care professional should assess the childs skin integrity before use reporting any concerns to the child’s medical team.

The current 2% chlorhexidine (CHG) and 70% isopropyl alcohol (IPA) device in the Trust is Chloraprep®. This guideline explains the use of this individual product and does not relate to any other 2% chlorhexidine and 70% isopropyl alcohol devices. Should the Trust change products this guideline will become invalid (Rationale 7).
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). There are two Chloraprep® products:

  • Sepp 0.67ml Peripheral cannulation and peripheral venepuncture for blood cultures.
  • Frepp 1.5ml Fistula cleaning, care and maintenance of indwelling CVADs, inserting central venous devices such as PICC lines, CVCs, Port-caths and Intraosseous needles.

Application of Chloraprep® - under the age of two months

  • This applies to all neonates with intact skin including those below 32 weeks gestation and less than two weeks of life.
  • 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® after the dressing is applied 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. 

 
Application of Chloraprep® - over the age of two months 

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.

Rationale

Rationale 1: This was approved by the Infection prevention and Control Committee in November 2010 and remains the recommendation of the Trust.  There have been no reported adverse events through the Datix system.

Rationale 2: The Trust has acknowledged that at present the infection risk of taking a single venepuncture 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; this applies to obtaining vascular access of any form.

Rationale 4: This will ensure consistency of skin preparation. Pooling of the solution has been reported as a contributing factor to adverse skin reactions. 

Rationale 5: Some products require different application techniques. Using the incorrect application method and drying time could adversely affect the effectiveness of the device used. 

Rationale 6: This will ensure that the skin is disinfected in a manor appropriate for the patient.

Rationale 7: If an alternative product is used, these guidelines will need to be reviewed to reduce the risk of another product being used incorrectly and cause  trauma to the patient's skin.

Rationale 8: The product contains glass vials that are broken on activation.

Rationale 9: As advised by manufacturer Carefusion (2010a, 2010b).

Rationale 10: Skin contamination can occur as a result of re-palpating the skin after cleansing. Therefore re-cleansing will be required to sufficiently decontaminate area (Scales 2009).

References

Carefusion (2010a) Product Education and Usage Information  
[last accessed 12.08.15]

Carefusion (2010b) Product Education and Usage Information
[last accessed 15.10.15]

Chesshyre, E., Goff, Z., Bowen, A. and Carapetis, J. (2015) The Prevention, Diagnosis And Management Of Central Venous Line Infections In Children. The Journal of infection. Jun;71 Suppl 1:S59-75

European Medicines Agency (2014) PRAC Recommendations on signals. EMA/PRAC/490498/2014. (Last accessed 15/10/2015)

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

Harron, K., Mok, M., Parslow, R., Muller-Pebody, B., Gilbert, R and Ramnarayan, P. (2014) Risk of bloodstream infection in children admitted to paediatric intensive care units in England and Wales following emergency inter-hospital transfer. Intensive Care Medicine. 40:1916-1923.

Loveday, H.P, Wilson, J.A,  Pratt, R.J, Golsorkhi,M. Tingle, A., Bak, A., Browne, J., Prieto, J. and  Wilcox, M. (2014) epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England.  Journal of Hospital Infection. 86:1 pp. S1-S70.

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

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. 

Royal College of Nursing (2010) Standards for infusion therapy. http://www.bbraun.it/documents/RCN-Guidlines-for-IV-therapy.pdf [last accessed 12.08.15]

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

Document control information

Lead Author(s)

Ashley Nadine Hurford, Practice Educator, Cardiorespiratory Unit

Document owner(s)

Ashley Nadine Hurford, Practice Educator, Cardiorespiratory Unit

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
20 December 2010
Date approved: 
15 October 2015
Review schedule: 
Three years
Next review: 
15 October 2018
Document version: 
3.0
Previous version: 
2.0