As a Family Resource Center nurse, I have learned a lot from my families about living with central venous catheters (CVCs), also known as “lines.” I worked with a group of specialists that included a central line specialist, a Child Life specialist, a social worker, an occupational therapist and a physician to create a class that teaches caregivers about living with a central line. In this, the first of a two-part blog, I worked with Meghan Meehan, nurse practitioner and CVC consultant. We will first talk about certain aspects of caring for a line at home, such as using good hygiene and organizing supplies. In the second part, we will talk about the challenges of living with a CVC, including how to access helpful resources and how to help siblings cope with changing family dynamics.
Good hygiene begins with good hand and skin care by the caregiver, patient and everyone in the home. Handwashing should be done using warm water and soap and a lot of friction. Make sure you wash your thumbs, in between fingers, and under fingernails as these are often forgotten areas. Scrub your hands for 30 seconds, which is about two rounds of singing “Happy Birthday” or “Yankee Doodle.” After rinsing the soap off with warm water, first dry your hands off using a clean towel or paper towel, and then turn off the faucet using a clean part of the towel.
You should have hand gel or sanitizer available in between and during line-related tasks. Every time you access the line to flush or give medications, you should clean your hands with either soap and water or sanitizer. Focus on the task, and if you accidentally touch your face, hair or anything else, use the hand sanitizer again before starting the task. If there is any visible dirt on your hands, you must wash them again. Also, your hands should be healthy enough to work with central lines. For example, if you have a nail fungus or hand infection, you should not touch the line as this could expose the line to infection-causing organisms. In addition, your nails should be short. If you wear nail polish or gel, your nails must not be chipped since germs can get trapped in the chips. You should not wear nail onlays or artificial nails since they harbor bacteria.
Good hygiene also requires good skin care for the patient. The child with a CVC needs a daily bath to keep his or her skin clean. The child’s teeth and gums need to be cleaned twice a day to help decrease bacteria in the mouth.
When flushing the lines, giving medications, or changing the dressings and caps, you should pay attention to the environment. CVC care should not take place in the kitchen or bathroom. Ceiling fans should be turned off and windows should be closed so that dirt is not blown around during care of the line. You should focus on the tasks and not talk or sing a lot during the procedure. You should use a clean, nonporous surface, such as a new acrylic cutting board or tray, to hold CVC supplies. Before laying supplies out, you should clean the surface with alcohol wipes or other disinfectant wipes.
Central lines, including PICC lines, have to be flushed at least once a day and before and after every medication. Every time you access the line, you must clean the cap. You must not touch the end of the syringe or the cap after cleaning.
Some caregivers have to learn how to change the caps and dressings on CVCs. Accessing the line and changing the cap are high-risk tasks that require a lot of concentration. The dressing change also has several steps. Children tend to dislike any tape removal, so they may not find it to be a pleasant task. For that reason, you should remove the dressing using adhesive remover with gentle motions. Amanda Brown, who is a Child Life specialist at CHLA, suggests doing something fun and unique only on dressing-change days, such as finger painting, playing in the bathtub, reading a special story or watching a favorite movie.
Caregivers must take steps to prevent contamination of supplies during a dressing change. One way to prevent contamination is to open supplies and leave them cradled in the packaging until they are ready to be picked up. Sanitizing hands in between steps, such as taking off the old dressing and cleaning the skin, is very important. Cleaning requires a certain amount of time to work properly. You should scrub the caps or “hubs” with alcohol for 20 seconds and air dry for 10. When scrubbing the hub, use friction as if you are juicing an orange. For dressing changes, you should clean the site for 30 seconds and fully air dry. Do not blow on the skin or caps to speed up the drying and do not wave your hands. Count out loud so that you scrub for the right amount of time. Practice all the tasks of caring for the line, from flushing and priming lines to dressing and cap changes, before you go home. Work with your health care professional to make sure you feel confident and comfortable.
Once you know the steps and the importance of not contaminating the lines, you should make sure everyone touching the line uses proper techniques to keep the line free of infection. If you notice any chance of contamination, you can respectfully correct any health care provider.
Organization of supplies
When CVC supplies are delivered, they need to be organized and stored safely. Some children with CVCs may need medications or parenteral nutrition at home. These are vital tasks and may involve many steps and technical skills. To help make the tasks easier and to prevent rummaging through boxes, organization of the supplies is really important. Nurses recommend bundling supplies that are needed for the same task. CHLA nurses use special bundles and kits when doing dressing and cap changes because this method ensures supplies are available and minimizes line-related complications. Organization does not have to be fancy or expensive. You can make plastic baggies with labels for flushing, dressing changes and cap changes. Alternatively, you can use Tupperware containers or rolling carts with drawers. It is important to have one special bag or rolling cart for emergency supplies, which would include:
- Sterile gauze
- A blue clamp
- Alcohol wipes
- Saline flushes
- A list of medications
- A list of allergies
- Specifics of the line, such as when it was placed, by whom, the type of catheter, the size and length, and any special notes about it
Know what to do if things go wrong. Contact your child’s doctor right away for any line breakage, leaking or clogging. In addition to contacting your doctor, plan to come to the Emergency Department if your child has a fever or other signs of infection such as redness, swelling or pus at the central line site. Keep a list of emergency numbers including the pharmacy and supply company and which nurse or doctor to contact in the event of an emergency.