KEEPING CL STARTS STERILEThe ICU RN role in placing central lines at the bedside

Lori Ritter RN, BSN, CNRNVicki Beck RN, MN, CNS, CNOR, CNRN

Pre-planningAssure informed consent…Have patient or family

sign consent for procedure unless emergentDiscuss with proceduralist planned insertion site and

planned medicationsSedationPain managementPossible paralytic

If time, physician/PA to write med orders. If not meds may be over-ridden in Omnicell for emergent administration.Make sure orders are written by physician/PA prior to

leaving the unit

Patient ReadinessIf patient aware enough, explain what to

expectHead may be placed in trendelenberg and

covered with drapeNurse’s role

Provide comfort, communication, administration of meds

Position patient to top of bedPlace chux under and around area of

insertionPlace towel roll between shoulder blades for

SC site

Prepare for Emergency1000 mL normal saline in-line for fluid

resuscitation if orderedAmbu bag connected to O2 sourceNRB mask if not ventilatedYankaur connected to suction and turned onReversal agents for sedation and pain

medications ~especially if not intubated

Prepare the Room AreaArrange bed with clearance for proceduralist

to access ptClear the over bed table completely – wipe

clean with Sani-ClothPosition spotlight to shine on insertion sitePlace garbage can close for easy target

Prepare monitoring equipmentPatient attached to EKG, SaO2, BP cuff with frequency of BP

taken Q 5 mins once procedure is underwayBedside monitor readied with appropriate insertion screen

pulled up (esp with PA catheter insertion)Pressure modules and cables inserted

Prime pressure tubing using 500 mL NS. Place in pressure bagTransducer/s can be leveled and zeroed prior to insertion

Vigilance monitor set-up for ScVO2 TL catheter or CCO PA catheterAsk if physician plans for in-vitro or in-vivo calibration

Most lean toward the in-vivo calibration because of sterile field contamination with the in-vitro calibration

Utilize critical elements if unsure of procedure

Ultrasound equipmentSonosite ultrasound in room and ready to go

Sterile sleeve availabilityKnow how to navigate the screens the

proceduralist will need to get to. You will be pushing the buttons as they are sterile Power button Depth Transducer choice View change

Central Line CartCart should in room, opened, with expected

needed supplies pulled prior to procedureIf isolation room, cart will remain outside of

room Designate a helper to pass through any additional

items during procedureEveryone in room during procedure will need

to wear a mask and bouffant cap ~at minimumAssisting RN should be prepared to step into

sterile field Have ready sterile gown and properly sized sterile

gloves

Supplies to pullMaximum barrier PPE for proceduralistThis is included in the CVC triple lumen kitIf not utilizing the CVC TL kit, pull the

following for proceduralistBouffant capMask with eye guard OR mask and goggles (if

not wearing glasses)Sterile gown2 pairs appropriately sized sterile gloves

Supplies, cont.Catheter to be placed

CVC TL catheter kitScVO2 TL catheter kitIntroducer kit and correct PA catheterTransvenous pacing wire and temporary pacemaker if needed

Full body sterile drape

30 mL vial of NS along with syringe and needle for flushing catheter portsProceduralist may pull up, or RN may squirt into the well of

kit….taking care to not contaminate sterile field (i.e. do not reach across)

Stopcocks and caps for line

Replacing a CLIf procedure is to replace an old CL:

Need all new IV drips, tubings, and in-line filters Prepare prior to procedure

NEVER connect old IV’s to new central line

Prepare the PatientAssure informed consentProvide patient comfort with position, meds, face

shieldAssure “time out” and document

Hand Hygiene/Mask/Cap/Gown/Glove

Drape the PatientSurgeon will lay drape on pt chest and openAssist by touching only under side of drape to

openDrape is not to move once opened – so

balance weight of drape or anchorRespect sterile field – Avoid reaching over or

touching

Maintaining the sterile field:Place only sterile items within the sterile field. Open, dispense, and transfer items without contaminating

them.Do not allow unsterile personnel to reach across the sterile

field or to touch sterile items.Do not allow sterile personnel to reach across unsterile

areas or to touch unsterile items.Recognize and maintain the service provider's sterile area.If a sterile barrier has been wet, cut, or torn, consider it

contaminated.Do not place sterile items near open windows or doors.When in doubt about whether something is sterile, consider

it contaminated.

Defining the ICU RN’s rolePRIOR

Make sure all supplies needed are in room, and room set-up is conducive to the flow of the procedure. Know physician/PA’s expectations for specifics.

WASH HANDS and roll up your sleeves Don bouffant cap and mask to wear throughout procedure Use sterile procedure when working close to sterile field.

Do not brush against, lean over, or touch, unless you are wearing sterile gloves. If you are the one placing the supplies on and preparing procedure sterile field, do not leave room after this has occurred to assure maintenance of sterility.

Defining the ICU RN’s roleDURING

Perform ‘Time Out’ at the start of procedure Provide comfort to patient throughout procedure through

communication, pain and sedation medication, and touch as able Assist physician in the placement of the full body sterile drape by

grabbing from underneath and pulling down completely over body Monitor patient’s O2 sats, HR, BP, sedation and pain levels and

intervene as needed. Provide ongoing communication of patient status with physician/PA as procedure is underway

Assist as required with procedure (i.e. Anticipate need for trendelenberg position, if requested make sure PA catheter calibrated prior to insertion, don sterile gloves if assistance needed in sterile field, assist with Sonosite manipulation). ScVO2

catheter will be calibrated after placement ( in-vivo)

AFTERDiscuss disposal of the sharps with physician/PA to

assure appropriately doneMonitor and recover patient from procedural sedationMonitor for all s/s of possible complications (i.e.

pneumo after central line placement, etc….)Follow up with physician regarding post procedure

CXR result and clearance to utilize placed linesComplete the Central Line Insertion QI form. Return

front page to Bill and second copy to GSRMC QI dept.Document in NUR and assign individualized

interventions Include notation about the “Time Out”

Defining the ICU RN’s role

Prevention of CLABSICentral Line Associated Blood Stream InfectionHand hygieneMaximal barrier precautions

Proceduralist to wear cap, mask, goggles, sterile gown and gloves

Sterile full body drapeChlorhexidine skin antisepsis

At insertion Daily CHG bath while patient in ICU

Optimal catheter site selection Avoidance of the femoral vein

Daily review of the line necessity; with prompt removal of unnecessary lines

Maximum barrierMaximum barrier PPE for

the proceduralist is a standard of care and required for all CL placements

SHS is tracking all CL placements for 100% compliance

RN is empowered to stop procedure if full sterile PPE is not being utilized. If full PPE declined, must fill out unusual occurrence report

Defining the ICU RN’s roleCelebrate your commitment to keeping our patients safe!