Notes

Module Four: Patient Safety- Pre-procedure Verification and Central Line Placement /Maintenance

Objective 1: Elimination of Wrong-Site, Wrong-Patient, and Wrong-Procedure Surgeries

A JCAHO safety goal is to eliminate wrong-site, wrong-patient, wrong-procedure surgery. Harborview has developed a “Universal Surgery/Procedure Protocol” (verification of patient, procedure, site, and team accountability). It is an administrative policy and procedure that:

*Addresses any surgical or invasive procedure in the outpatient and inpatient setting.

*Covers the OR, procedural, and bedside settings.

*Requires verification of the patient’s identity, consent, and site marking. This includes a final “TIME OUT” check we call a “PPV” (pre-procedure verification), which includes:

Correct patient
Correct side and site (with marking of site)
Agreement of procedure to be done
Availability of implants, special equipment or other special requirements
Correct positioning

*The Operating Room has additional requirements to the "Time Out."

*Exempts the site marking requirement in crash/emergent cases where the delay could cause potential harm to the patient.

*Also exempts minor procedures, such as N/G placement and venipuncture.

*Requires documentation that the PPV has been completed.

Objective 2: Pre-procedure Verification and Central Line Placement /Maintenance

NOTE: This content does not apply to tunneled or long-term vascular access devices, such as Groshong, Hickman and PICC lines. Please refer to the relevant HMC policies and procedures related to these lines.

This content will review the current HMC policy and best practices reported in the clinical literature. Checking the right patient, right procedure is one of the most basic, but vital methods of ensuring patient safety. Central lines are a frequent source of nosocomial infection in all areas of the hospital. Avoiding catheter-related infections is the responsibility of all members of the healthcare team and effects the insertion, maintenance and removal. Please note new additions to the previous standards are noted in italics.

Nurses and physicians should use proper hand hygiene (soap and water or hand gel) prior to inserting, accessing or dressing any central line.

Pre-Procedure Verification

Prior to any elective line insertion, the nurse and physicians should complete a pre-procedure check or “time out.” This is a brief pause that allows patient and procedure verification. It is also an opportunity to ensure that all needed equipment is present; that the patient is in the proper position and is pre-medicated if needed, which enhances patient safety during the procedure.

Objective 3: PPV & Sterile Technique Checklist

Objective 4: Site Selection, Preparation, Barriers and Resources

Site Selection

Routine use of femoral sites should be discouraged, as they are associated with higher rates of infection. The preference of order should be: subclavian, internal jugular, then femoral.

Site Preparation

Sites should be prepped with a chlorhexidine preparation (Chloraprep). Dry areas should be cleansed for 30 seconds and allowed to dry for 30 seconds. Moist areas (e.g. inguinal folds) should be cleansed for 2 minutes and allowed to dry for 1 minute.
Chlorhexidine provides superior skin antisepsis than other agents such as Betadine.

Maximal Barriers

During line insertion, physicians should use maximal protective barriers, including sterile gloves, gown, mask and cap.

Adequate Resources during Insertion

Standardized line carts are being developed to ensure that adequate supplies are easily available during line insertion procedures.
The nurse or their designate should be readily available during the entire procedure.
If the nurse assisting notices a break in technique during insertion. They are empowered by the revised Central Line Policy to STOP THE PROCEDURE.

Objective 5: Interventions to Prevent Infection When Central Line is in Place

Dressing Changes

Dressing changes should be completed every 24 hours or as needed when it becomes wet, soiled or non-occlusive.
Nurses should use physical barriers, including mask and gloves during dressing changes.
The site should be closely inspected for signs of infection, then cleaned with a Chloraprep solution, and then covered with a dry sterile dressing and tape.

Daily Evaluation

The need for a central line should be evaluated on a DAILY basis at a minimum. Unnecessary lines should be removed promptly.

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Last modified: 9/30/2005 1:09 PM