Community Nurse Referral PICC Cancer Patients - University ...

Community Nurse Referral Letter (PICC Care)
Name of nurse making the referral:
Name…………………………………………Signature…………..………………………………
Date………………Ward…………………………………….Tel 0845 1555 000 Ext………….
Dear Community Nurse
The following patient requires care for a PICC (Peripherally Inserted Central Catheter):
Name…………………………..………….…………………….….DOB………………………..….....
Diagnosis……………………………………………………………………………………………...…
Address………………………………………………………………….….…………………………………
……………………………………………………………………………………………………….…
Tel………………………….……..………GP……………………..…..………..……………………….
Please visit as follows………………………………………………………………………………………
…………………………………………………………………………………………………………………
………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………
………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
The PICC has been checked by X-Ray. If the line is pulled out by more than 5cm please inform
us. As a baseline please note that on discharge the measurement between hub and exit site was
as follows:
Page 1 of 7……continues overleaf
UCL Hospitals is an NHS Foundation Trust incorporating the Eastman Dental Hospital,
Elizabeth Garrett Anderson & Obstetric Hospital, The Heart Hospital, Hospital for Tropical
Diseases, National Hospital for Neurology & Neurosurgery, The Royal London Homoeopathic
Hospital and University College Hospital.

…continued. Please note
• We have recently stopped using hepsal for locking lines
• We have recently changed our exit site cleaning regime. We are now using Chloraprep ®
• Dressing change & flush are due weekly: instructions attached
• Blood tests: if required patient will be given blood forms with dates for when the tests are due.
Please take blood from the PICC and sent to your usual Path lab. Instructions attached.
• Print off your own copies of the attached information from our website at www.uclh.nhs.uk/cvc
A Note About Infection: Most patients on chemotherapy are immunocompromised and infections should
be acted on immediately.
♦ If the patient experiences a rigor and/or pyrexia following flushing of the line, contact the hospital
urgently. Haematology pts: contact 0845 1555 000 Bleep 1154. Oncology Pts: contact 07947 959 020.
♦ If the exit site is inflamed or there is purulent exudate, please take a swab. If the patient is pyrexial,
contact the hospital urgently as above. If not, this can wait until the next working day. The site should be
inspected daily while infection is suspected and use of Biopatch ® & Chloraprep ® should be
suspended until the infection has resolved.
♦ Handwashing and a non-touch technique are vital: please follow attached instructions.
Tick
PICC discharge checklist to be completed by nurse referring patient
Patient supplied with items in List A (see below). Subsequently supplied by community team.
Patient supplied with enough items in List B (see below).
Patient / carer knows to collect items from List B each time they attend the hospital
Copy of this referral to be faxed to you
Hard copy of this referral to be given to patient
Patient knows who to contact if they have a problem with their PICC
Signed………………………………………………………..Date………………………………
List A
• Dressing pack x 2
• Transparent dressings x 2
• Steristrips x 2
• 10 ml syringes x 10
• Green needles x 10
• Clinell wipes x 10
• 1 box 0.9% saline 10mls (IV use)
• Sharps bin
List B
• Chloraprep Sepp .67mls ®
• Statlock dressings
• Biopatch ®
• Bionectors
• Large yellow bags x 2 for disposal of
chemo (if required)
Page 2 of 7……continues overleaf
For advice or to arrange teaching contact Central Venous Access Team
Tel: 0845 1555 000 ext 77491. Email: centralvenousaccess@uclh.nhs.uk

Flushing a PICC
Community nurse referral for PICC Care page 3 / 7
• Our PICCs are fitted with Bionectors rather than bungs. These are needle-free access ports. YOU
SHOULD NEVER STICK NEEDLES INTO them, and they need to be changed once a week.
• Please treat each lumen separately, using a different syringe for each lumen.
• Most of our PICCs do not have clamps because each lumen has a valve which keeps air from
entering when the Bionector is changed.
Routine Flushing: weekly for unused lumens.
1. Wash hands. Draw up saline into syringes.
2. Clean end of Bionector with 2% chlorhexidine swab. Rub
vigorously for 30 seconds using different parts of the swab.
3. Allow to dry fully without becoming contaminated (OR if
Bionector change is due, remove Bionector, clean end of lumen
with alcohol swab, allow to dry, apply new Bionector and proceed.)
4. Remove needle from saline syringe. Push the syringe into the
Bionector and twist clockwise. The syringe should now stay in place.
Equipment Needed
per lumen
• 10 mls 0.9% Saline IV
• 10 ml syringe (no
smaller)
• Needle
• 2% Chlorhexidine in
alcohol swabs
• Sterile towel
• Spare Bionector if
change due
5. Flush the PICC using a brisk “push-pause” technique (ie pause after each ml: this creates turbulence
in the line and helps clear any tiny debris). DO NOT FORCE THE FLUSH or you may split the PICC.
If you meet resistance, STOP and contact the hospital for advice. Never use a smaller syringe to try to
unblock the PICC.
6. Remove syringe by twisting anti-clockwise while flushing in the last ml of saline. Leave Bionector in
place.
Taking blood from a PICC.
Equipment Needed
As for routine flush (above) but add:
• two extra empty 10 ml syringes (or
one extra syringe plus Vacutainer
connector)
• 2 x 10ml syringes of saline and a
spare in case PICC needs flushing
before it will bleed back.
1. Access the PICC using aseptic
technique as for flushing.
2. Withdraw & discard first 4mls of blood
from PICC. (If it won’t bleed back try
flushing the line first or ask patient to
take deep breaths.)
3. Take the blood sample.
4. Flush immediately with 2 x 10mls 0.9%
saline: turbulent push-pause flush.
Further info: Print off your own copy at
www.uclh.nhs.uk/cvc. Contact Nurse
Specialists: Tel: 0845 1555 000 x77491.
Email:centralvenousaccess@uclh.nhs.uk
Out of hours: Haematology patients
contact 0845 1555 000 Bleep 1154.
Oncology patients contact 07947 959 020.
Updated by Liz Simcock October 2009
If you are flushing off chemotherapy…
Chemotherapy can damage cells. Avoiding contact with
chemotherapy is like avoiding radiation in an X-ray
department. Repeated exposure can be harmful. This is
why it must be handled with care.
• Always wear apron and gloves when handling lines,
bags and infusion devices containing Chemotherapy
• Disconnect the giving set from the PICC leaving the
Bionector in place.
• Avoid dripping or splashing of the Chemotherapy.
• Dispose of contaminated equipment carefully in a
double yellow bag including the empty infusion device,
the syringe used to flush the line through and your
gloves and apron
• The yellow bag can be brought back to the hospital by
the patient at his / her next visit for disposal by the
chemotherapy nurses. In the meantime it should
always be stored out of the reach of children.
• Always wash your hands on removing your gloves and
apron.
In the event of a spillage
Chemotherapy can cause irritation if it comes into direct
contact with the skin. If for any reason this should happen,
flush the affected area with plenty of water and a mild
soap. If any burning or rash develops subsequently, seek
medical advice.

Chloraprep and Biopatch
Community nurse referral for PICC Care page 4 / 7
Chloraprep Sepp .67mls ® is a single-use sterile applicator containing a 2% solution of Chlorhexidine
Gluconate and 70% Isopropyl Alcohol. It’s coverage area is 5cm x 8cm.
• It works by penetrating the top 5 layers of the skin where most bacteria is found.
• At UCLH Cancer Services and Adolescent Cancer we are now using Chloraprep ® for cleaning all our
Central Venous Catheter exit sites including PICCs.
Can it be used for all patients?
• Patients must be aged 2 months and over.
• Adverse reactions are very rare but can cause anaphylaxis. Do not use on patients with a history of
hypersensitivity to Chlorhexidine.
How should it be used?
• Pinch the sides of the applicator once (in the middle of the ampoule) until you feel the
inner ampoule break. The antiseptic solution will soak the sponge tip.
• Use a gentle repeated back-and-forth friction rub for 30 seconds and allow to dry
completely.
• Discard in clinical waste bag.
• If there is loose blood or exudate around the exit site, clean this away using 0.9%
saline before using Chloraprep ® .
Biopatch ® is a disc-shaped foam dressing impregnated with Chlorhexidine
Gluconate. Biopatch ® inhibits bacterial growth.
• At UCLH we are now using it on all our Central Venous Catheter exit sites
including PICCs (except for patients under the age of 16).
Can it be used for all patients?
• Patients must be aged 16 or over.
• Adverse reactions are very rare but can cause anaphylaxis. Do not use on patients with a history of
hypersensitivity to Chlorhexidine.
How is Biopatch ® applied?
• The Biopatch ® should be placed around the PICC exit site with the BLUE side up
• The catheter should rest on top of the Biopatch ® near the radial slit.
• A IV-dedicated transparent dressing should then be applied. For patients unable to tolerate a
transparent dressing try a dry dressing (eg Mepore).
How often should it be changed?
• Change the Biopatch ® and the dressing every 7 days or sooner if
the dressing becomes detached
the Biopatch ® is more than half discoloured with blood / exudates
the white edges of the Biopatch ® become visible around edges of blue disc
What if the exit site looks infected?
• If the exit site is visibly infected: STOP using Biopatch ® & Chloraprep ® . Take a swab and contact the
GP or hospital. Change dressing daily and clean with 0.9% saline until the infection is resolved.
Do Chloraprep ® & Biopatch ® need prescribing & can they be obtained in the Community?
• They do NOT need to be prescribed. They can be hard to obtain in the Community. Patients should be
sent home with a supply and should collect a few more each time they visit the hospital.
Further information: Print off your own copy of attached info at www.uclh.nhs.uk/cvc
Contact Nurse Specialists: Tel: 0845 1555 000 x77491. Email: centralvenousaccess@uclh.nhs.uk.
Out of hours: Haematology patients contact 0845 1555 000 Bleep 1154. Oncology patients contact 07947 959
020. Updated by Liz Simcock October 2009

Changing a PICC Dressing
Community nurse referral for PICC Care page 5 / 7
Clean hands & put
on non-sterile gloves
Remove dressing
DO NOT pull on
PICC!
Remove steristrip
DO NOT pull on
PICC!
Gently remove
Biopatch
Remove Statlock
DO NOT pull on
PICC!
Prise off transparent
wings & remove
Statlock
Squeeze Chloraprep
Sepp to soak
sponge
30 seconds friction
rub back & forth
(covers 5 x 8 cm)
Allow to dry
Attach new Statlock
dressing
DON’T pull on PICC!
Prepare skin using
skinprep pad
(in Statlock pack)
Apply Statlock
Curve PICC away
from elbow joint
Clean hands again
Put on sterile gloves
Apply Biopatch
Apply Steristrip
Apply transparent
dressing
Further information: Print off your own copy of attached info at www.uclh.nhs.uk/cvc
Contact Nurse Specialists: Tel: 0845 1555 000 x77491. Email: centralvenousaccess@uclh.nhs.uk.
Out of hours: Haematology patients contact 0845 1555 000 Bleep 1154. Oncology patients contact 07947 959
020. Updated by Liz Simcock October 2009

PICC Troubleshooting
Community nurse referral for PICC Care page 6 / 7
Patient is pyrexial (above 38 o C) and / or experiences a rigor:
• Contact the hospital urgently for advice. May need IV antibiotics.
Exit site looks infected (inflammation / exudate around exit site)
• If the patient is pyrexial see above.
• Take a swab.
• Contact the hospital or GP. May need oral antibiotics.
• Stop using Biopatch ® until infection resolved.
• Daily dressing changes if exudate is present & clean with 0.9% saline.
Sore, swollen inflamed arm above the PICC insertion site –
• Contact the hospital. This might be a thrombosis.
PICC is blocked:
• Contact the Central Venous Access Team (see contact details below).
PICC will not bleed back:
• If you are just doing a routine flush don’t worry. If you need to administer iv
medications or take blood samples contact the Central Venous Access Team.
PICC has been pulled out by more than 5cm:
• Must be x-rayed before continuing with treatment. Contact the hospital.
PICC has been cut, split or damaged:
• Fold the line over on itself between the break and the patient and secure with tape.
This will prevent air entry. Contact the hospital. PICC may need to be removed (see
below) but note that PICCs can sometimes be repaired.
If the PICC needs to be removed
1. Check your manager is happy for you to remove PICC
2. Place PICC exit site below the level of the heart.
3. Remove the dressing.
4. Pull PICC out slowly an inch or two at a time.
5. If you meet resistance, STOP. Do not risk snapping the line.
6. Resistance may be due to venospasm. Wait 5 minutes before resuming.
Applying warm packs to the patient’s arm may help. If not, contact the hospital.
7. Once the PICC is out, apply pressure to the exit site with sterile gauze.
8. Apply air-proof dressing.
Equipment
• Non-sterile gloves
• Gauze swabs
• Air-proof dressing
Further information: Print off your own copy of attached info at www.uclh.nhs.uk/cvc
Contact Nurse Specialists: Tel: 0845 1555 000 x77491. Email: centralvenousaccess@uclh.nhs.uk.
Out of hours: Haematology patients contact 0845 1555 000 Bleep 1154. Oncology patients contact
07947 959 020. Updated by Liz Simcock October 2009

Central Venous Catheter Care Training for
Community Nurses
Ever wished you knew more
about Hickmans, Portacaths
or PICCs?
One-off teaching sessions for Community Nurses.
Cost: £20
This is not a substitute for IV training but we do cover:
• What is a Central Venous Catheter?
• Hickmans, PICCs and Portacaths
• Flushing and Dressing techniques
• Recognising and Preventing Complications
DATES FOR 2012
27 th Jan / 22 nd March / 17 th May
12 th July / 6 th Sept / 31st Dec
All sessions 14.30 – 16.30
Obtain application form by:
email: centralvenousaccess@uclh.nhs.uk
phone: 0845 1555 000 ext 77491