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The Royal Free Hampstead NHS Trust

Peripheral Intravenous Cannulation Clinical Guidelines and Procedures Adult and Children's Services

August 2009

Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services. Page 1 of 34 CF & SMcK August 2009

Validation Grid Title Primary Author Peripheral intravenous Cannulation clinical guideline and procedures Caterina Falce Matron, Immunology and Transplantation Steve McKenna Lecturer Practitioner Child Health Medical Practitioner, Nurses and Midwives, Allied Health Care Professionals. Trust-wide Clinical Practice group Clinical Practice group Directorates: Specialist Services, Transplant and Immunology, Urgent Care, Trauma and Managed Networks, Private practice, Cannulation team Advance Practice Consent Policy Infection Control Guidelines, Intravenous Sodium Chloride 0.9% flushes NMC "The Code: Standards of conduct, performance and ethics for nurses and midwives" Cannulation - procedures for adult peripheral intravenous cannulation 2007 Paediatric Cannulation & Phlebotomy Workbook 2009 August 2009 Update August 2011 PIC, Aseptic Technique, Documentation, Children and Young People, Adult

Target Audience Service Group Commissioning body Stake holders consulted

Clinical Practice / Advanced Practice Associated Policies / Documents

Guideline Replacement

Date of submission Date of Review Key words

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Validation Grid .................................................................................................................. 2 1. 2. 3. Introduction ............................................................................................................... 5 Aim ............................................................................................................................. 5 Staff who can undertake the procedure .................................................................. 5 3.1 3.2 3.3 3.4 4. 5. 6. 7. Qualified Nursing and Midwifery staff who may undertake this procedure ........... 5 Criteria for application to undertake nurse cannulation ........................................ 5 Training pathway for nursing and midwifery staff ................................................. 6 Previous experience in cannulation ..................................................................... 6

The role and responsibility of nominating managers ............................................ 6 Documentation .......................................................................................................... 6 Non-registered staff who may undertake this procedure ...................................... 6 Supervised practice guidelines ............................................................................... 7 7.1 To support supervised practice the following criteria must be met ....................... 7

8. Criteria to be an Assessor and Assessment Guidelines for Intravenous Peripheral Cannulation .................................................................................................... 7 8.1 9. Guidelines for assessment ................................................................................... 8

Peripheral Intravenous Cannulae available at the Royal Free .............................. 9 9.1 Gauge Size ............................................................................................................. 9 10.1 Recommendations for Cannula Choice - 2 ........................................................ 11

11 Best practice Recommendations:.......................................................................... 11 11 Improving venous access- dilating the veins ....................................................... 12 11.1 12. 13. 14. 15. 16. 17. 18. Best practice Recommendations: ...................................................................... 12 Considerations when selecting the Vein ........................................................... 12 Consent ................................................................................................................ 13 Equipment Required ........................................................................................... 14 Use of a needless system ................................................................................... 14 Procedure ............................................................................................................. 14 Procedure for caring for PIC............................................................................... 15 Flushing PIC......................................................................................................... 17

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19. 20.

Aims of securing the device with a dressing .................................................... 17 Removal of PIC .................................................................................................... 18

Criteria for Cannula removal ......................................................................................... 18 21. Procedure for Removal of PIC ............................................................................ 18

22. Potential problems and complications of Peripheral Intravenous Cannulation: ................................................................................................................... 18 22.1 22.2 22.3 22.4 22.5 22.6 22.7 22.8 22.9 22.10 23 Missed Vein ....................................................................................................... 19 Haematoma ....................................................................................................... 19 Infiltration and Extravasation .............................................................................. 19 Inflammation and infection: ................................................................................ 19 Infusion Phlebitis and Thrombophlebitis ............................................................ 20 Cellulitis.............................................................................................................. 20 Bacteraemia ....................................................................................................... 20 Septicaemia ....................................................................................................... 20 Pain .................................................................................................................... 21 Psychological problems .................................................................................. 21

References ........................................................................................................... 21

24 Appendix 1 Certificate of Competence for Peripheral Intravenous Cannulation (PIC) ........................................................................................................... 25 25 Appendix 2 Veins of the Forearm ............................................................................ 28 26 Appendix 3 Phlebitis Scale Chart ............................................................................ 28 27 Appendix 4 Extravasation Scale Chart .................................................................... 28 28 Appendix 5 Patients Requiring Chemotherapy ...................................................... 29 29 Appendix 6 High impact intervention audit forms...........................................28 30 Appendix 7 Equality impact assessment ................................................................ 28

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1. Introduction Peripheral intravenous cannulation (PIC) is a skilled process that involves a number of stages and is increasingly being performed by nurses in a variety of clinical settings (Scales 2005). Intravenous therapy is an indispensable part of treatment for many patients (Parker 1999); Therefore developing knowledge and skills through training in the insertion and care of peripheral intravenous cannula is vital (Castledine 1996). In response to increased freedom provided within the Scope in Practice (NMC 2005) and the The Code (NMC, 2008) there has been a move for nurses and midwives to cannulate (Inwood 1996). A number of factors need consideration when introducing cannulation into an organisation or department (Jackson 1997; and Scales 2005). It is the aim of these guidelines to address these considerations. 2. Aim The aim of cannulation is to insert a peripheral intravenous cannula (PIC) by maintaining peripheral intravenous devices safely, including patency of lines and prevention of complications during insertion and maintenance. 3. · · · Staff who can undertake the procedure Medical practitioners Nurses and Midwives including Heath Care Assistants (HCA) following training and competency assessment Cannulation team members following training and competency assessment

3.1 Qualified Nursing and Midwifery staff who may undertake this procedure Peripheral intravenous cannulation (PIC) is considered to be an advanced practice within this Trust. An advanced practice may be defined as an aspect of care which may be undertaken by registered nurses/midwife/cannulation team and who have undergone the specified training and assessment, accept accountability for their actions and feel competent to undertake the aspect of care. PIC is considered a practice that every midwife is expected to demonstrate competency in following registration. 3.2 Criteria for application to undertake nurse cannulation The opportunity for registered practitioners, HCA's to perform cannulation exists to provide continuity of care. In response to the increased freedom provided within Scope of Practice (NMC 2005), nurses require a sound basic theoretical knowledge to be able to perform such a technique. There is little evidence to quantify how much practice is required to become competent in cannulation, but experience suggests that two issues are important: 1. initially a high level of exposure is required to learn the skills 2. regular practice (at least once per week) is required to maintain the skills It is only appropriate to develop nurses' roles if: 1. the development is in the best interest of the patient 2. skills, knowledge and competencies are maintained 3. nursing practice is not fragmented or compromised by the development of this practice

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This means that the introduction of nurse cannulation must be carried out in appropriate areas by trained nurses, midwives, health care assistants and other health care professionals and must not disrupt delivery and continuity of nursing care. 3.3 Training pathway for nursing and midwifery staff Before staff undertakes assessment for this practice they must have completed the following steps: 1. Agreed with their line manager/ PDN (Practice Development Nurse) during their SDR that it is appropriate to take on this practice as part of their role 2. To undertake this training staff must be prepared to commit time to the achievement and maintenance of competencies. 3. Have an identified mentor and assessor (with advice from line manager or the lead nurse for quality and development) and must be within their own department 4. Be assessed as competent in practice intravenous drug administration according to Trust policy 5. Complete the distance learning workbook and attend the Royal Free workshop on peripheral intravenous cannulation within a 3 months timeframe. 6. Gain supervised practice with a member of staff who is an assessor (see section 4) If the nurse moves to another clinical area it is the responsibility of the practitioner to discuss with their line manager whether continuing with cannulation in the new work environment is still in the best interest of the patient. 3.4 Previous experience in cannulation If the practitioner has previous experience in cannulation in another trust, he/she must produce evidence to their manager/PDN and will be at the manager's discretion to assess if the practitioner requires full training in accordance with the PIC training at the Royal Free Hampstead NHS trust. 4. The role and responsibility of nominating managers By nominating a member of staff to undertake cannulation training the nominating manager is agreeing to support their staff by protecting the time they need to work with their mentor/assessor. 5. Documentation In line with the NMC (2005, 2008) guidelines on standards for records and record keeping there must be a current and appropriate plan of care for each patient. The plan must incorporate on-going evaluation and reassessment of care and evidence that relevant interventions and observations have been communicated to appropriate members of the multidisciplinary team. On insertion of a cannula the following should be documented: name of the practitioner inserting the cannula insertion site size of cannula date of insertion 6. Non-registered staff who may undertake this procedure Non-registered staff may also undertake training and assessment for this practice, as long as it is appropriate to take on this practice as part of the role for which they have been

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employed to do. Non-registered staff must follow the same training pathway as for nursing staff with the exception of being trained in intravenous drug administration. These staff will be nominated from specific clinical areas by their managers. Before they undertake the assessment they must have completed the following steps: 1. Be nominated by their line manager 2. Have an identified mentor and assessor 3. Attend a workshop on peripheral intravenous cannulation 4. Gain supervised practice with the mentor/assessor 5. The requirement of undertaking PIC should be contextual to the clinical area in which the practitioner is working. 6. Receive training in the use of Patients Groups Directive for the use of intravenous saline flushes. 7. Supervised practice guidelines Supervised practice is the period of training and supervision, under the direction and leadership of a mentor/assessor. Following a period of observation and learning in liaison with your mentor/assessor, together you will take a joint decision about when you are ready to commence your practice. 7.1 · · · · To support supervised practice the following criteria must be met (nurses and miwives only) Be a registered practitioner with a minimum of one years post registration experience Be competent in the advanced practice of peripheral intravenous cannulation for a minimum of 6 months Carry out advanced practice of peripheral intravenous cannulation on a regular basis When supporting supervised practice you should sign the student's supervised practice record everytime you observe them in practice

8.

Criteria to be an Assessor and Assessment Guidelines for Intravenous Peripheral Cannulation Assessment has been defined by Nicklin and Kenworthy (2000) as a "measurement that directly relates to the quality of learning and as such is concerned with student progress and attainment". A nursing assessor must fulfil the following criteria: · Be a registered practitioner at band 6 or above · Provide evidence that they have completed a course that incorporates the principles of assessment and supervision of practice · Be competent in the advanced practice of peripheral intravenous cannulation for a minimum of 6 months · Have been assessed as competent in cannulation and undertake cannulation on a regular basis (i.e. 2 to 3 times per week) · The assessor can nominate a PIC supervisor to support the staff member during their PIC training. He/she must have a minimum of 6 month experience in PIC, working within the clinical area, being competent and up to date in accordance to trust policies. However the supervisor cannot complete the assessment process. To assess non-nursing staff the assessor must meet he following criteria:

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· · · ·

Provide evidence that they have completed a course that incorporates the principles of assessment and supervision of practice e.g. NVQ assessors course A1 or equivalent Be competent in the advanced practice of peripheral intravenous cannulation for a minimum of 6 months Have been assessed as competent in cannulation and undertake cannulation on a regular basis (i.e. 2 to 3 times per week) The assessor can nominate a PIC supervisor to support the staff member during their PIC training. He/she must have a minimum of 6 month experience in PIC, working within the clinical area, being competent and up to date in accordance to trust policies. However the supervisor cannot complete the assessment process.

Each registered practitioner is accountable for his/her actions or omissions (NMC, 2008). As an assessor your judgement may be questioned if a practitioner whom they assessed as competent makes a mistake because they were clearly not competent to carryout peripheral intravenous cannulation. Assessing competence means that it is not sufficient that the practitioner merely demonstrates manual dexterity and good clinical skills. They must also demonstrate an understanding of the underlying theory that supports their practice. This involves giving clear rationale for their actions. It is implicit upon the practitioner, once assessed as competent, that they are clear of the limitations of undertaking the procedure and those circumstances where it may be inappropriate for it to be undertaken. It is up to the assessor and the practitioner to decide when the assessment should take place. The setting should be that in which the practitioner usually practices. If you are in any doubt as to the individuals' competence you should suggest that the practitioner is reassessed at a future date. You can then discuss the areas of weakness that need to be improved upon and devise an action plan. The assessment criteria (certificate of competence) are retained by the practitioner for personal reference, but a copy of the assessment criteria is given to the individuals' line manager (paediatric staff ­ original document to be kept in file at ward/department level and photocopy of the same document given to the PDN). If you have any questions regarding assessment of this advanced practice please contact the Nursing Directorate ext 35554. 8.1 · · · · Guidelines for assessment Arrange an initial meeting with the assessor presenting your completed workbook. Appoint a supervisor at the initial meeting if necessary Set up a plan of action and intermediate interview at 6 weeks Aim for final assessment around week 12.

To carry out an assessment you must: · Set a date to meet with the practitioner to complete the practical assessment. All sections of the assessment criteria (certificate of competence) must be completed. · You must observe a minimum of 5 PIC carried out by the practitioner. Where possible the observations should be of a number of different insertion sites and if possible, a selection of different patient groups.

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·

Once the practitioner has demonstrated competence, the assessor can sign the certificate of competence

It should be remembered that all practitioners are ultimately accountable for their own practice and should only carry out practice that is within their sphere of competence. Once a practitioner has completed a competency assessment, it remains the responsibility of the individual practitioner to remain clinically and professionally up-to-date. Practitioners will need to provide evidence of continued professional development at their staff development reviews; this can be achieved though the completed competency or attendance at a cannulation update session (see training department for details). 9. Peripheral Intravenous Cannulae available at the Royal Free Introcan safety non ported/winged IV cannula available trust wide Neoflon ( Neonates and Paediatrics) Introcan safety non ported/non winged IV cannula (Theatres) Vasofix safety ported IV cannula (Theatres speciality use) Some cannulas not specified may be available in speciality areas for specialty use; please see local guidelines.

9.1 Gauge Size Scales (2005) recommends using the smallest gauge needle and shortest length into the most accessible peripheral vein, with the largest diameter and the greatest blood flow, which would allow for satisfactory administration of the therapy. Smaller gauge cannulas are less likely to cause a through puncture of the vein and allow increased blood flow around the catheter thus diluting irritant drugs. They have less chance of causing phlebitis and thrombus. Larger gauge cannula rub against the intimae of the vein and may precipitate the development of phlebitis thus decreasing blood flow around the cannula

Gauge 14 Colour Orange Length 2 inch · · · · · · Uses And Considerations when large volumes of fluid must be infused trauma patients patients for major surgery pregnant women may be used for adolescents and adults rapid infusions (often used in theatres) · · Comments large vein required insertion is painful

16

Grey

2 inch

18

Green

1 ¾ inch

· surgical patients · blood transfusions of more than 4 units · blood components, TPN & other viscous fluids · may be used for older children, adolescents & adults Use a larger gauge in a larger vein to infuse caustic or viscous solution

· ·

large vein required insertion is painful

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· · 20 Pink 1 ¼ inch · · 22 Blue 1 inch ·

may be used for adolescents & adults suitable for most intravenous infusions and up to 4 units of blood patients requiring IV fluids/drugs but not surgical intervention suitable for most infusions including red cells, plasma and clear fluids may be used for infants, toddlers & children adolescents, adults - esp. the elderly

·

commonly used

· · ·

easier to insert in small thin fragile veins slower flow rates must be maintained difficult to insert into tough skin Requires extremely small veins e.g. fingers, lower portion of inner arms May be difficult to insert into tough skin

24

Yellow

¾ inch

· · ·

Neonates, infants, toddlers Adolescents, adults (esp. elderly) with small veins Suitable for most infusions but with slower flow rates including chemotherapy

·

·

Cannulas for blood transfusion: Standard intravenous cannulas are suitable for blood component infusion. All blood components can be slowly infused through small bore cannulas or butterfly needles e.g. 21 G. For rapid infusion, large bore cannulas e.g. 14 G are needed. Handbook of Transfusion medicine 4th edition, Editor DBL McClelland, TSO, London

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Recommendations for Cannula Choice - 2

Gauge Colour 19 beige 21 green 23 blue 25 orange Steel Butterfly · Can be used for once only bolus injections at doctors request in special circumstances · Steel needle is inflexible & can cause trauma & infiltration · Generally only used for phlebotomy · Not to be used for chemotherapy, even if single dose Uses & Considerations · Ideal for cannulation on a hand, finger or inner aspect of a wrist if access is poor · can be used for once only bolus injections at doctors request if access is poor Comments · The steel needle once removed leaves a small plastic cannula · The cannula are small, sharp & short · Cannula are easy to insert

Butterfly Cannula 16-24

11 Best practice Recommendations: When possible avoid veins that are: · · · · · · · · · · · · · · · · on the dominant arm/hand too superficial thrombosed or fibrosed directly over joints - particularly the cubital fossa region which is used for blood sampling & interferes with arm flexion tortuous, bruised or infected in oedematous limbs in an area of extensive scarring e.g. healed burns in limbs with lymphoedema near a previous haematoma in an arm with an arteriovenous shunt or fistula in areas of skin inflammation, disease or breakdown below a previous IV infiltration/phlebitis site hardened or sclerotic on the inner wrist or arm as they are small and thin walled uncomfortable for the patient difficult to secure For patients with renal problems, consideration when selecting veins should be given to patients without a shunt who may need one in the future.

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11 Improving venous access- dilating the veins It is necessary to dilate a vein in order to insert a PIC. The application of a tourniquet should promote venous distension, however light tapping of the vein may be used, but not too hard as this can be painful. The use of rubber gloves is highly inappropriate (Dougherty 1996). There is little supporting literature about how to apply the tourniquet. Jackson (1997) suggests that the tourniquet is applied 10 cm above the insertion site. Dougherty (1996) adds that it should be tight enough to restrict venous return, but not to affect arterial flow. Additionally, opening and closing of the fist forces blood into the vein, causing them to distend (Dougherty 1996). A good `rule of thumb' is to place 3 fingers under the tourniquet during application. However in Children's Services a second person using their hand can be an effective way to engorge the vein thus facilitating a sufficient blood flow/amount. 11.1 1. 2. 3. 4. Best practice Recommendations: If cannulating the forearm apply the tourniquet above the elbow If cannulating the forehand apply the tourniquet below the elbow Tap the veins lightly to encourage dilation Ask the patient to gently open and close their fist (excessive fist clenching has been reported as causing pseudo hyperkalaemia 5. Use gravity to encourage dilation of the veins 6. Emla is not licence for use under 1 years old, however Ametop can be used on any age and takes 30 minutes post application to be effective (cream should be removed after 1 hour to prevent skin from burning) the effect of the cream will last up to 5 hours 7. If these measures are unsuccessful, remove the tourniquet and apply heat e.g. bowl of hand warm hot water to promote blood flow and aid vein dilation.

12. Considerations when selecting the Vein A knowledge of anatomy and physiology is essential, both for the selection of a site for cannulation and the prevention of intravenous-related problems. The individual should be able to distinguish a vein from an artery. The inadvertent administration of intravenous drugs into the arterial system may seriously compromise the circulation to the involved limb (Jackson 1997). Veins do not have a pulse and empty with digital pressure (Jackson 1997). Palpation of the vein is important in determining the condition of the vein. Dougherty (1996) lists criteria for a good vein: · are bouncy & soft · are well supported · refill when depressed · are visible & straight · have a large lumen Some research suggests those cannulaes located over mobile joints (without immobilisation of the joint with a splint) are more at risk of phlebitis and extravasation (Jackson 1997). However Stonehouse & Butcher (1996) found no correlation between phlebitis and cannula inserted near a joint, but 65% of patients complained of discomfort and restricted movement.

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Dougherty (1996) discovered that patients value the time that nurses spend finding the appropriate vein. Moreover they appear to gain a sense of control from being asked their preference of vein to cannulate. Veins suitable for peripheral intravenous cannulation include those on the dorsum of the hand and the cephalic and basilic veins of the forearm (Jackson 1997). The vein should be well supported. The selected vein should be suitable for the fluid prescribed. Small vessels will not accommodate large volumes of fluid or irritant solutions. The vein should be situated on the distal part of the patient's limb, but proximal to previous attempts (Terry et al 1995). Jackson (1997) highlights two potential problems following distal insertion: · Irritant substances may be routed past an area of inflammation, thereby prolonging the inflammation process · Leakage from the primary site; this will cause extravasations injury if vesicant substances are used. The veins of the antecubital fossa should be preserved for venous sampling (Jackson 1997) and veins in the feet should be avoided due to the increased risk of deep vein thrombosis (Jackson 1997). In addition the vessel should not show any signs of thrombosis or bruising (Jackson 1997). At times it will be necessary to insert a cannula in a scalp vein or feet. This should only be undertaken by competent skilled practitioners (paediatricians, paediatric nurse practitioners and emergency physicians). 13. Consent Prior to the insertion of a PIC, the patients' verbal consent must be obtained, (Scale, 2005). It is also important to provide an explanation of the reason for cannulation, duration of the intended therapy and associated risks (Scales, 2005, NMC 2002). It is important to ensure that adequate information is provided to the patients so that they can make an informed decision. In the event that the recipient of the cannula does not understand English, it is incumbent upon the health practitioner to engage an appropriate translator (not a family member) to ensure that the above discussion takes place and it clearly documented in the medical record. Consent to cannulate a child/ young person must be obtained from the person who has parental responsibility, biological mother always has parental responsibility unless removed by the court ( Children's Act, 1989 and 2004)

13.1 Legal and Ethical Issues Related to PIC: The patient has the right to refuse to have a PIC. You may try to obtain their consent by gentle reassurance and explain the reasons for a PIC. However the patient's choice is

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final. If a patient refuses to have a PIC inform, the doctor who ordered the insertion of a PIC. If patient cannot speak English, an interpreter is required to positively identify the patient. In relation to children and young people, parental consent will be sought. 14. Equipment Required Ametop ® / Emla ® cream Cannula choice as per table 10.2 DisposableTourniquet Cannulation IV pack Alcohol gel hand rub Needless system extension Clinell ® wipe (alcoholic 2% Chlorhexidine) Gloves & plastic apron 5mls Sodium chloride 0.9% (prescribed) & 10ml syringe Tegaderm IV (3M) dressing 80.5 litre portable sharps bin

15. Use of a needless system The needle less system is a needle free, closed IV access system. It provides improved staff safety as it reduces the number of needles used and reduces the risk of staff coming into contact with blood. Risk of infection is also reduced as the system is closed with a self sealing bung. This system can be used with all peripheral cannulae with and without an extension 16. Procedure Intervention

®

Rationale To obtain consent and co-operation Local anaesthetic cream applied 30 minutes prior to painful procedure

Explain the procedure to the patient Offer Ametop Emla

®

Whenever possible, undertake cannulation Provide a clean, calm environment in the treatment room Wash hands and put on apron, assemble Prevent cross infection and prepare necessary equipment. Flush needless system extension). To prevent air embolism Examine arms for suitable location of To identify most suitable vein to cannulate cannula Discuss choice of vein with patient (if Inform selection of cannula site appropriate) and obtain verbal consent. If hair removal necessary and patient Reduce the risk of inflammation at the consents, clippers should be used. Do not cannulation site shave. Pack Preparation To minimise risk of infections use aseptic technique

Place patient in a comfortable position with Aids patient safety and comfort. the chosen limb supported by a pillow. Wash hands, put on non-sterile gloves. Gloves are used as part of universal Only use sterile gloves if the patient is precautions except in neutropaenic patients

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neutropaenic.

where they are required to protect the patient.

Apply a tourniquet to arm to dilate veins by Provide easy access to vein obstructing venous return Clean the skin for at least 30 seconds with To reduce risk of healthcare associated Clinell® wipes (alcoholic 2% infection Chlorhexidine)to cover a 1 inch radius and allow to dry Gently pull the skin taut below the proposed To anchor and immobilise the vein insertion site. Insert the cannula smoothly at a 30o angle to the skin and level off as soon as the back flow of blood appears. Advance the catheter hub into the vein To ensure cannula advanced along the keeping the needle in a stationary position vein. looking for a flashback of blood along the catheter (this may not always happen). Remove tourniquet and dispose into the To prevent build up of blood leading to yellow bag haematoma and prevent infection Apply two strips of sterile tape from the To anchor the cannula dressing (see diagram) Apply pressure on the vein beyond the To minimise leakage needle and then remove the needle by removing the needle. holding the catheter hub in place. Attach the needless system bung of blood while

Reduces need to manipulate cannula

Check for flashback of blood and then flush To ensure the vein is cannulated and that with 5 mls of normal saline 0.9% the cannula is cleared of blood. Cover insertion with TegadermTM dressing. Provide details for ongoing care Sign and date the dressing In children and young people splints as To stabilise cannula site supported with bandages are applied. Anchor the needless system connector with Prevent pulling on vein tape Dispose of sharps in the sharps bin, waste To reduce risks of contamination and into yellow clinical waste bag, remove sharps gloves and apron and wash hands. Record cannulation in nursing record Provide ongoing evaluation

17. Procedure for caring for PIC Intervention Rationale Ensure date, time and site of insertion and To provide information for evaluation and any nursing interventions related to the maintain accountability cannula are recorded in the patient's

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nursing notes Aseptic technique must be used at all times To prevent introduction of pathogens when caring for the cannula and during drug/fluid administration Cannula must be anchored securely using Prevents trauma to the vessel wall and the sterile strips from the Tegaderm 3M IV dislodgement of the cannula. dressing. The insertion site must not be obscured. Giving sets must be anchored securely using tape, e.g. Micropore. (Berry et al, 1986. Davidson, 1986 & Ringer, 1987). If patient has a bath or shower check To protect cannula and integrity and waterproof dressing and contamination of the dressing change as appropriate The cannula must also be protected if the patient has a bath or shower. The site should be dressed with Tegaderm Provides a sterile, vapour permeable 3M IV dressing and ensures the insertion site is easily observed The dressing must be replaced and site Moist environments should be prevented as cleaned with Clinell ® wipe (alcoholic 2% they encourage the growth of pathogens Chlorhexidine) using an aseptic technique, if moisture or blood are present under the dressing Cannula used intermittently should be To prevent cannula blocking flushed 6 hourly with Sodium Chloride 0.9% which must be prescribed or by using PGD ( Patient Group Directive ) if applicable Following the administration of a bolus drug To ensure the whole dose is given the flushing solution should be given over Reducing the risk of irritation approx. 30 seconds appropriate to the drug that was administered unless otherwise indicated. In certain circumstances cannula should not be flushed after drug administration i.e. Iloprost- (please see individual protocols) If a drug is administered using an infusion To ensure the rate of drug administration is line, the rate of administration of the not exceeded. flushing solution should not exceed the rate at which the drug was administered The cannula should be observed during Early detection of problems and prevention each interaction with the patient. If the of consequences patient complains of pain or has any signs of phlebitis or extravasation use the following scales (see appendix 3 and 4) to record the severity of the problem and determine action required. Incident form

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prevent

needs to be completed. Following a blood transfusion the PIC To minimize the risk of embolus infusion should be flushed immediately. Document interventions in the appropriate To maintain accountability and record 12 hours cannula document in the in-patient keeping. booklet Note: If the cannula is being used for Parental Nutrition administration, then a 5mg GTN patch must be placed distal to the cannula and changed daily. 18. Flushing PIC

18.1 Indications for flushing · 6 hourly to maintain patency or before use to verify the patency of an IV cannula if it is not being used continuously · Between IV drug administrations to prevent drug interactions · After initial cannula insertion to prevent clotting in the cannula · To clear the cannula after a drug or infusion has been administered Note: If a cannula is being used for the administration of parenteral nutrition, it does not need to be flushed between infusions. It only needs to be flushed when there is a planned break between PN bags or at the end of the therapy. 18.2 Solutions for flushing Sodium Chloride 0.9% is the commonly used fluid for flushing IV cannula. However, it is not compatible with all drugs so check for potential interactions. Refer to the ward pharmacist if there are any queries. Water for injection should only be used where it is specifically required to prevent interactions as it damages red blood cells. A 10ml syringe is recommended when administering a 5 ml flush to reduce the pressure in the vein. (Juan 1993) 19. Aims of securing the device with a dressing After insertion the cannula should be covered with a sterile dressing to reduce the risk of contamination. Jackson (1997) suggests that the dressing should: · keep the cannula secure · allow easy inspection of the insertion site · keep the cannula site clean and prevent entry of bacteria · be easy to apply and remove · prevent the build up of moisture beneath the dressing Should the dressing become loose or contaminated it must be replaced. The continuing care of the cannula is an integral part of the nurse's role. To identify early signs of intravenous problems the cannula should be checked before any additives or at minimum 12 hourly (Jackson 1997).

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20. Removal of PIC Criteria for Cannula removal · cannula should be changed every 3rd day however in children and young people change as necessary ( Bregenzer et al 1998, Webster et al, 2008) · Blocked cannula · Evidence of extravasation · Evidence of phlebitis/infection · Redundant cannula (no longer required) 21. Procedure for Removal of PIC Equipment required: Disposable gloves and apron Sterile dressing pack Intervention Discuss plans to remove cannula with the patient Collect required equipment, wash hands, put on gloves Remove the cannula using an aseptic technique Hold a piece of dry cotton wool or gauze over the insertion site and remove the cannula carefully, using a slow steady movement and keeping the hub parallel to the skin Apply pressure until bleeding stops Clean the site with sterile saline (if necessary) and dress with a waterproof elastoplast dressing. If phlebitis or extravasation has been diagnosed, plan further intervention as per scale. (see appendix 3 and 4) Request insertion of new cannula if required Document removal of cannula in patient notes noting reason for removal

Cotton wool or gauze Waterproof sterile dressing

Rationale Patient informed about plan of care Reduce infection risks Prevent the introduction of pathogens To prevent damage to the vein (Dougherty 1999) In neutropenic patients sterile gauze must be used. Prevent blood loss and bruising Prevent pathogens entering whilst the site heals Prevent further complications

To continue IV treatment To provide a record and baseline for observation

22. Potential problems and complications of Peripheral Intravenous Cannulation: Jackson (1997) and Hindley (2004) list potential problems associated with peripheral intravenous cannulation: · Missed vein · Haematoma · Infiltration · Extravasation · Infection · Thrombus · Infusion phlebitis In addition pain and psychological problems are also associated.

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22.1 Missed Vein There are several reasons why a vein may be missed during the insertion procedure: Inadequate vein anchoring/stretching allows the cannula tip to push the vein aside. Failure to recognise when PIC has gone through the opposite vein wall ­ will be indicated by diminished blood flow. When stopping too soon after the PIC insertion, so that only the stylet and not the PIC enter the lumen of the vein. This becomes apparent when blood return disappears when the styled is removed. When inserting the PIC too deep, below the vein. This is evident when the cannula will not move freely because it is embedded in muscle. The patient may complain of severe discomfort. Failure to penetrate the vein wall because of improper insertion angle (too steep or too flat) causing the cannula to ride on top of or below the vein. 22.2 Haematoma Haematoma is caused by raised intravascular pressure when the tourniquet is not released promptly and the vein is cannulated. Or when the vein has been punctured during the insertion process but missed (see above) 22.3 · Infiltration and Extravasation Refer to non-cyto guidelines in the Clinical Practice Manual.

22.4 Inflammation and infection: "Peripheral intravenous cannula insertion will be carried out by trained and competent staff using strictly aseptic techniques" (DoH, 2003). More than 60% of patients admitted to hospital are likely to receive therapy via an intravenous device (Wilson, 2001). With so many patients undergoing treatment via peripheral cannula, nurses have a professional duty to recognise and prevent associated complications, acting always to "protect and support the health of individual patients/clients" (NMC, 2002). Infections associated with the peripheral intravenous cannula are intrinsically linked with commensal skin flora (Hindley 2004). The most frequent life threatening complication is septicaemia, caused either by the device used for vascular access or from contamination of the infusate administered (Maki et al, 1991). Skin flora and cross infection by patients and staff are factors involved in cannula related Staphylococcus infections. It is thought that skin organisms may be introduced into the wound at the time of the insertion of the peripheral cannula or later when organisms migrate along the interface between catheter and tissue (Maki et al, 1991).

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There are several types of inflammation or infection associated with IV cannula, which may be minimised if strict asepsis is used throughout the life of the cannula and the IV site is closely monitored (Pratt et al, 2007). These have been classified as: 22.5 Infusion Phlebitis and Thrombophlebitis Phlebitis is defined as the acute inflammation of a vein wall by chemical or mechanical irritation with subsequent complications of infection and thrombosis (Stonehouse & Butcher, 1996, Parker 1999, Hindley 2004). Mechanical irritation occurs when the cannula rubs against the vein wall, while chemical irritation is due to drugs or intrinsic contamination of fluids (Dougherty, 1997). Patient discomfort can often be the first indication of complications such as phlebitis. Phlebitis scales measure the severity of phlebitis in terms of local redness, pain, swelling and the development of a palpable venous node (Stonehouse & Butcher 1996; Wilson 2001). The size of the cannula and the device design are also important considerations when considering phlebitis (Dougherty 1996). In a pilot study to test new aspects of IV management Stonehouse & Butcher (1996) found that larger cannula lumen appeared to increase the likelihood of mechanical phlebitis (Stonehouse & Butcher 1996). Additionally, the use of large cannula causes more pain than the smaller devices. Therefore the smallest suitable cannula should always be selected and situated in the largest vein possible. This combination will allow for efficient haemodilution of substances that are administered intravenously (Jackson 1997), thus reducing the incidence of phlebitis. The composition of the cannula material is also shown to reduce the incidence of phlebitis. Cannula made of Vialon have less surface defects and prevent adhesion of platelets and proteins (Kerrison and Woodhall 1994). Additionally Vialon absorbs water thus increasing its plasticity and reducing the incidence of phlebitis (Kerrison and Woodhall 1994; Jackson, 1997). Moreover, 90% of patients reviewed by Stonehouse & Butcher (1996) preferred Vialon for comfort. 22.6 Cellulitis This can be defined as the Inflammation of the skin tissue caused by invading bacteria such as staphylococcus aureus. It is characterised by local heat, redness, pain and swelling. Fever and general malaise may also be experienced. 22.7 Bacteraemia Bacteraemia is the presence of bacteria in the blood (demonstrated by blood culture) in the absence of systemic signs of sepsis. Potentially is caused by introduction of pathogens to an IV site. This may occur in various ways such as poor asepsis during insertion, "tracking" down the cannula from skin surface, or through poor technique when using the cannula. 22.8 Septicaemia Systemic infection in which pathogens are present in the circulating blood stream having spread from an infected focus e.g. infected PIC site with associated clinical signs and symptoms

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The best therapeutic measure when an infection occurs or is suspected is to remove the cannula this not only negates the infective cause but, also simultaneously protects the lumen from further physiochemical trauma (Hindley 2004) 22.9 Pain The cannulation procedure is often painful. Topical anaesthetic agents can reduce the pain of peripheral intravenous cannulation (Scales 2005). Topical anaesthetic cream has to be applied two hours prior to cannulation. This is not always practical and has vasoconstriction properties which may further complicate cannulation (Gunwardene & Davenport 1990). However the use of a fast acting cream is a good alternative as it is effective after 10 minutes and has mild vasodilatation effects (Scales 2005). It is also advised by Scale (2005) that local anaesthetic should be removed before cannulation because prolonged skin contact has been associated with skin damage 22.10 Psychological problems The fear of pain, needles and injections is a common phenomenon among the general population which can become exaggerated when people are ill (Castledine 1996; Davies 1998). Anxiety can exacerbate the pain and trauma of the procedure and may lead to non-compliance and refusal to treatment (Davies 1998). Fainting and refusal of life saving treatment are labelled as a phobia and need prompt recognition and management. In order to prevent phobias acquired by conditioning, the insertion of the cannula should be undertaken by someone who has acquired skill through constant practice. Technical confidence, minimising pain, diversion distraction, relaxation techniques and good communication skills all help to reduce the stress associated with IV cannulation (Dougherty 1996).

23 References

Berry, R. Franecki, M. & Sunser, S. (1986) Abstract of presentation, NITA Conference, May. New Orleans, USA Bregenzer, T.et al, (1998) Is routine replacement of peripheral intravenous catheters necessary? Archives of internal medicine 26:158(2): 151-6 Cahill, M (1991) Clinical Skillbuilders ­ IV Therapy. Springhouse Corporation. Springhouse, Pennsylvania. Castledine, G. (1996) Nurses' role in peripheral cannulation. British Journal of Nursing, 5, 20, 1274. Creamer E (2000) Examining the care of patients with peripheral venous cannulas. British Journal of Nursing 9 (20) 2128-2144 Davies, S. (1998) The role of nurses in intravenous cannulation. Nursing Standard, January 14, 12, 17, 43 - 46.

Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services Page 21 of 34 CF & SMcK August 2009

Davidson, L. (1986) Dressing subclavian catheters. Nursing Times. Feb. 12, 82, 40. Department of Health (2001) Reference Guide to Consent for Examination or Treatment. The Stationery Office, London Department of Health (2003) Saving lives. The Stationary Office, London Department of Health (1989 and 2004) Children's Act. London Dibble, SL et al (1991) Clinical Predictors of Intravenous Site Symptoms. Research in Nursing and Health, 14: 413 ­ 420 Dougherty, L. (1996) Intravenous cannulation. Nursing Standard, 11, 2, 47 - 54. Dougherty, L. (1997) Reducing the risks of complications in IV therapy. Nursing Standard, 12 (5) 40 ­ 42 Dougherty, L. (1997) reducing the risk of complications in IV therapy. Nursing Standard, October 22, 12, 5, 40 - 42. Hindley G (2004) Infection Control in peripheral cannula. Nursing Standard. 18,27, 37-40 Inwood, S. (1996) Designing a nurse training programme for venepuncture. Nursing Standard, February 14, 10, 21, 40 - 42. Jackson, A. (1997) Performing peripheral intravenous cannulation. Professional Nurse, October, 13, 1, 21 - 25. Kerrison, T. & Woodhull, J. (1994) Reducing the risk of thrombophlebitis: a comparison of Teflon and Vialon cannula. Professional Nurse, 9, 10, 662 - 666. Maki, DG & Ringer, M. (1991) Prevention of Infection associated with central venous and arterial catheters. Journal of the American Medical Association. 258. Maki, D. et al (1991) Prospective randomised trial of povidone-iodine, alcohol, and chlorhexadine for prevention of infection associated with central venous and arterial catheters. Lancet, 338, 8763, 339 - 343. Morbidity and Mortality Weekly Report (2002) Guidelines for the Prevention of Intravascular Catheter-Related Infections. 51 (10) 1-36 NMC (2002) Code of professional conduct Nursing & Midwifery Council. London NMC, (2005) Scope in Practice. Nursing & Midwifery Council. London NMC, (2005) Guidelines for records and record keeping. Nursing & Midwifery Council. London

Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services Page 22 of 34 CF & SMcK August 2009

NMC, (2008) The code: Standards of conduct, performance and ethics for nurses and midwives. Nursing & Midwifery Council. London Parker L. (1999) IV Devices and related infections: British Journal of Nursing. 8: (22) 1491-1498 Peters, JL et al, (1984) Peripheral venous cannulation: reducing the risks. British Journal of Parenteral Therapy. 5 56 ­ 58 Pettit & Hughes (1993) Intravenous Extravasation: Mechanisms, Management and Prevention. Journal of Perinatal and Neonatal Nursing. March 69 ­ 79 Pratt, RJ et al, (2007) Epic 2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS in England. Journal of Hospital Infection. 65S: S1-S64. Royal College of Nursing Infection Control Association (1994) Intravenous Line Dressings ­ Principles of Infection Control. RCN. London Sedgewick, J. (1997) We must assess the care we give: nursing practices in invasive procedures. Professional Nurse, 5, 11, 624 - 630. Shoal, J. & Oliver, S. (1992) Efficacy of Normal saline injection with and without heparin for maintaining intermittent Intravenous sites. Applied Nursing Research, 5 (1): 9 ­ 12 Scales K (2005) Vascular access: a guide to peripheral venous cannulation. Nursing Standard 19 (49): 48-52 Stonehouse, J. & Butcher, J. (1996) Phlebitis associated with peripheral cannula. Professional Nurse, October, 12, 1, 51 - 54. Terry, J., Baronowski, L., Lonsway, R., Hendrick, C. (1995) Intravenous therapy: Clinical Principles and practice. Philadelphia, W.B. Saunders. United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1992) The Scope of Professional Practice. London, UKCC. Webster,J. et al (2008) Routine care of peripheral intravenous catheters versus clinical indicated replacement. BMJ:337:a339 Wilson, JE (1991) Preventing Infection during IV therapy. Professional Nurse, July: 388 ­ 392 Wilson, J. (1994) Prevention of infection during IV therapy. Professional Nurse, 9, 6, 388 392. Wilson J. (2001) Infection Control in Clinical Practice. Second Edition. London Bailliere Tindall.

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Wood, L. (1993) IV Vesicants: How to avoid extravasation. American Journal of Nursing. April, 42 ­ 46

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24 Appendix 1 Certificate of Competence for Peripheral Intravenous Cannulation (PIC) Peripheral Intravenous Cannulation (PIC)Supervised Practice Assessment Criteria Performance criteria Met Not Met Knowledge Is able to describe the normal anatomy & physiology of the venous system Demonstrate understanding of the various cannula sizes which may be requested List the criteria used for choosing the vein for PIC Explain how to choose the correct equipment for PIC Describe the potential complications of PIC and the appropriate action to take Skills Assesses and plans appropriate care in conjunction with the patient/client giving appropriate information, and maintaining dignity and comfort throughout the procedure Chooses the appropriate equipment and prepares the environment appropriately Demonstrates ability to choose an appropriate site and vein Demonstrates use of the principles of infection control Use of aseptic technique Is able to deal with potential problems Demonstrates safe handling of body fluids and disposal of sharps & waste Awareness/Attitude Registered Nurses: Recognises own competency level and can explain implications of accountability when undertaking an advanced practice Non-registered staff: Recognises need to maintain competence through practice and further education where needed. All - Recognises the individual needs of the patient/client and deals with them sensitively Date Supervised Practice Comments Signature 1

2 3 4 5 6 7 8 9 10 Date Formal assessment comments Signature

I feel I have received sufficient theoretical knowledge and supervised practice to undertake the advanced practice of peripheral intravenous cannulation Name of practitioner: Signature Of Practitioner: Date: This practitioner has successfully met all the criteria for assessment Name of assessor: Signature Of Assessor: Date:

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25 Appendix 2 Veins of the Forearm

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26 Appendix 3 Phlebitis Scale Phlebitis Scale Score Criteria Action No pain At IV site, no No action erythema ( redness ), no swelling, no induration, no palpable venous cord Painful IV site, with or Continue to use IV cannula without erythema, no but observe site for swelling, no induration, changes no palpable venous cord Painful IV site with erythema and swelling, and with induration or a palpable venous cord < 3 inches above the IV site Painful IV site with erythema, swelling, induration and a palpable venous cord > 3 inches above the IV site. Infusion may have stopped running due to thrombosis. Pus may be present Remove cannula, clean and dress site, inform medical staff, document action

0

1+

2+

3+

Remove IV cannula, clean and dress site, continue to observe site, inform medical staff, document action

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27 Appendix 4 Extravasation Scale Chart Extravasation Scale Score 0 Criteria No evidence of infiltration at IV site Mild infiltration with an area of extravasation measuring <1'' x 1'' and <2'' x 2'' Action No action Stop infusion, remove cannula, elevate limb, dress site, observe for changes, inform medical staff, complete incident form Stop infusion, remove cannula, elevate limb, dress site, observe for changes, inform medical staff, complete incident form Stop infusion, remove cannula, elevate limb, dress site, observe for changes, inform medical staff, complete incident form

1+

2+

Moderate infiltration with an area extravasation measuring >1'' x 1'' and 2'' x 2''

3+

Severe infiltration with an area of extravasation measuring >2'' x 2''

Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services Page 28 of 34 CF & SMcK August 2009

28 Appendix 5

Patients Requiring Chemotherapy

Past Medical History · Axillary node clearance or lymphoedema - Do not use this limb to cannulate because of poor venous/lymphatic return and an increased risk of infection. · For similar reasons, patients with Superior Vena Cava Obstruction (SVCO) have a higher risk of extravasation, and the medical team should be consulted. These patients should not receive cytotoxics peripherally. Treatment · Chemotherapy administered peripherally should only be given via cannula and no other venous access devices e.g. butterfly cannula (see North London Cancer Network Guidelines for the Safe Prescribing, Handling and Administration of Cytotoxic Drugs for further information). · If a patient has poor venous access a central venous access device should be considered, for example, a Hickman line. Alternatively a PICC line or Porto-cath may be appropriate. · The vein should be situated on the distal part of the patient's limb, but proximal to previous attempts. This reduces the risk of extravasation around the primary leakage site (see guidelines). For similar reasons be aware of venepuncture sites in the antecubital fossa. Use the other limb if necessary. · Cytotoxic agents range in classification between non-irritant, irritant and vesicant substances. When a vesicant is to be administered veins between the wrist and the elbow should be used. However, do not use the antecubital fossa for administering cytotoxic agents, as there is an increased risk of extravasation. Ideally dorsal, radial and ulna veins should not be used for vesicants; they tend to be superficial and fragile veins and so have a higher risk of extravasation. Good veins should be used for irritant and vesicant veins. Most common are; Median cubital, basilica and cephalic veins. · Additionally, avoid thrombosed or fibrosed veins. Using bruised or infected veins will prolong the inflammation process and so should also be avoided.

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29 Appendix 6

PERIPHERAL LINE INSERTION ­ REVIEW TOOL Date............................................................................ Sterile field, e.g. dressing towel Yes No Skin cleaned with 2% Chlorhexidine Yes No Semipermeable, transparent dressing Yes No Safe disposal of sharps Yes No Hand hygiene post Intervention documented All elements performed

Ward...........................................................................

Observation

Clinical indication

Hand hygiene prior

Personal protective equipment Yes No

Yes 1 2 3 4 5 6 7 8 9 10

Total Number of observations Total number of observations where compliance achieved

No

Yes

No

Yes

No

Yes

No

Yes

No

% compliance Name...................................................................... Signature .....................................................................

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PERIPHERAL LINE CARE ­ REVIEW TOOL ­ CONTINUING CARE Ward...........................................................................

Observation

Date............................................................................ Hand hygiene prior Personal protectiv e equipme nt

Yes No

Continuing Site clinical inspected indication

Dressing intact

Line insitu > 72 hrs

Sterile field, e.g. dressing towel

Yes No

Ports cleaned with 2% Chlorhex -idine

Yes No

New syringe for each flush

Yes No

Safe disposal of sharps

New line if required

Interventi on documen t-ed

Yes No

All elements performe d

Yes No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

1 2 3 4 5 6 7 8 9 10

Total Number of observations Total number of observations where compliance achieved

% compliance Name...................................................................... Signature .........................................................................................

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30 Equality Impact Assessment

Equality and Health inequalities Impact Assessment Screening Checklist

Name of policy/service Is this a new or existing policy/service Purpose of the policy/service Stakeholders in policy/service development Person responsible for policy/service impact assessment Proposed date for implementation of policy/service

Peripheral intravenous Cannulation clinical guideline and procedures

Review of existing policy To provide guidelines to staff to ensure quality of practice See validation grid Caterina Falce and Steve McKenna August 2009

Do you think the policy/service will impact upon any group within the population based upon: Race/ethnicity Gender Religion/belief Disability (including long term conditions and mental health) Age No No No No No Looked after children Population groups more at risk of developing certain conditions (based on community health profile data) Any other groups Lower socio-economic groups Involvement in the criminal justice system Homelessness No No No No No

Sexual orientation or gender identity

No

No

What impact will the policy/service have on lifestyles? For example: Diet and nutrition Exercise and physical activity Substance use; tobacco, alcohol, drugs Risk taking behaviour Education and learning or skills Functional ability Quality of life Will the policy/service have any impact on the social environment? For example: Social status Employment (paid or unpaid) Social/family support Stress Income Will the policy/service have any impact upon: Discrimination? Equality of opportunity? Relations between groups? Improving uptake of services by under represented groups? Will the policy/service have any impact on the physical environment? For example: Living conditions Working conditions Pollution or climate change Accidental injuries or public safety Infection control Will the policy/service impact on access to and experience of services? For example: Healthcare Transport Social services Housing services Education

Caterina

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1.

Equality impact assessment screening checklist summary sheet Positive impacts (Note groups affected) 2. Negative impacts (note groups affected)

Promotes good practice for all groups.

None ­ no negative impacts currently but will monitor and review in one year.

3.

Additional information/evidence required

Data collection across equality strand groups.

4.

Recommendations

5.

As a result of completing the impact checklist, have any negative impacts been identified, and if so is a full impact assessment recommended?

No ­ policy promotes good practice. 6. If impact assessment has not been recommended please state the reasons why.

Data collection and validation required.

Date for completion of screening checklist review /completion of full impact assessment :

Managers name and signature: Steve McKenna Caterina Falce Approved by Operational manager for Equality and Diversity(name and signature) Jennifer Kenward

Date: 09/09/09 09/09/09 Date:

04.11.09

Caterina

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Caterina

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