HD-CL-008 · CVC Removal Criteria & Procedure (UPDATED)

Central Venous Catheter Removal Criteria, Procedure, and Post-Removal Care

Policy HD-CL-008 · Hemodialysis Unit

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To establish criteria for safe removal of tunneled and non-tunneled CVCs, standardize procedure to prevent air embolism and bleeding, and ensure documentation per KDOQI 2020, INS Standards, and MOH-Jordan 2023.

2 Scope

Applies to all RNs with HD-CL-003 CVC Competency. Physicians remove non-tunneled CVCs in ICU. RNs may remove tunneled CVCs only with MD order + specific training. Techs NEVER remove CVCs.

3 Definitions

Tunneled CVC Cuffed catheter – RN may remove if cuff exposed + MD order Non-Tunneled CVC Temporary, no cuff – MD removes only Exit Site Healing 24-72h post-removal Air Embolism Risk Highest during removal – patient flat or Trendelenburg

4 Policy Statement UPDATED

Update 1.1 MD order · 2-RN procedure · removal criteria

MD order required. Removal criteria must be met. 2-RN procedure. Never remove if active CRBSI with sepsis, coagulopathy, unless MD bedside.

Enhanced: • MD Order Required: No CVC removed without written order specifying reason. • Removal Criteria Met: CVC must meet Section 5 criteria before removal. • 2-RN Procedure: 2 RNs required for tunneled CVC removal – one removes, one monitors. • Never Remove If: Active CRBSI with sepsis, coagulopathy INR >3, platelets <50K, unless MD bedside. • Heparinized Patient: Hold heparin 4h before removal if possible. Reverse if urgent.

Rationale: CVC removal is a high-risk procedure. MOH requires documented criteria, 2-RN verification, and coagulopathy assessment.

5 Removal Criteria – All Must Be Met UPDATED

A. Indications – Remove CVC When:

Indication	Timeline	Who Orders	Notes
1. AVF/AVG Usable	2 consecutive HD sessions with 2 needles, Qb ≥300, no CVC used	Nephrologist	Primary goal – get CVC out ASAP
2. CRBSI Confirmed	Positive blood cx from CVC + peripheral	Nephrologist + ID	Remove 72h after abx start unless septic
3. Exit Site Infection	Purulence, tunnel infection not responding 48h abx	Nephrologist	Send tip for culture
4. CVC Malfunction	Flows <200 mL/min, TPA fails, cannot restore	Nephrologist	Replace vs remove depends on access
5. Patient Discharged	Transplant, modality change, hospice, recovery	Nephrologist	Document reason
6. Elective	Patient request after education	Nephrologist	Sign HD-CL-007-F6 refusal if no alt access
7. End of Life	Withdrawal of dialysis	Nephrologist + family	Palliative removal

B. Contraindications – Do NOT Remove:

No Alternative Access: AVF/AVG not ready + patient needs HD next 48h.
Coagulopathy: INR >3.0, PTT >80, Plt <50K, unless bleeding risk > clot risk per MD.
Sepsis + Unstable: BP <90 systolic, on pressors. Stabilize first unless CVC is source.
Skin Infection Over Site: Cellulitis at exit site – treat first, remove later.
Patient Refuses: Document HD-CL-007-F6. Cannot force removal.

C. Special Case: CRBSI Removal Timing – KDOQI

S. aureus, Pseudomonas, CandidaRemove immediately – day 0. High mortality if left.
Never save

Gram neg rodsRemove day 0-3 if septic. Can try save if stable.
If no sepsis + suscept abx

Coag-neg StaphCan try abx lock ×14d if no fever.
If 2nd episode, remove

Tunnel InfectionRemove immediately – never save

If septic shock: Remove immediately at bedside regardless of INR/Plt. Bleeding risk < death risk.

6 Procedure: Tunneled CVC Removal – 2 RN UPDATED

Phase 1: Prep5 minutesVerify order · Consent · Position flat/Trendelenburg · Timeout · Baseline vitals

Phase 2: Removal5-10 minutesSterile field · Clean · Lidocaine · Remove sutures · Valsalva · Pull slow steady traction · Immediate pressure

Phase 3: Hemostasis10-15 minutesPressure 10-15 min · If bleeding, call MD · Petroleum gauze · Air-occlusive dressing · Label

Phase 4: Post-Removal30 minutesVitals q15min ×2 · Site check · Position flat 30 min · Discharge instructions

Equipment Checklist (HD-CL-008-F1): Sterile gloves ×2, mask ×2, gown, sterile drape, 4x4 gauze ×10, 2x2 ×5, Chlorhexidine swabs ×3, suture removal kit, 3-0 nylon suture + needle driver, petroleum gauze, pressure dressing, specimen cup, biohazard bag.

Phase 1: Prep – 5 minutes

Verify Order: MD order with reason. Check INR/Plt if coagulopathic.
Consent: Explain procedure, risks: bleeding, air embolism, retained cuff. Patient signs HD-CL-008-F2.
Position: Flat or Trendelenburg. Turn head away from side. Prevents air embolism.
Timeout: 2 RNs verify patient, site, order. Document HD-CL-008-F3.
Vitals: BP, HR, O₂ sat baseline.

Phase 2: Removal – 5-10 minutes

RN #1: Sterile gloves/gown. Drape site.
Clean: Chlorhexidine 30 sec. Dry.
Anesthesia: 1% lidocaine at exit site if cuff adherent. Wait 2 min.
Remove Sutures: If present at exit site.
Patient Breath: "Take a deep breath and bear down" – Valsalva maneuver. Or "hum" if can't bear down. Prevents air entry.
Pull CVC: Slow steady traction parallel to vein. If cuff resistance, stop. May need blunt dissection by MD. Never cut catheter – can embolize.
Immediate Pressure: RN #2 applies pressure with 4x4 over venotomy site + 2x2 over exit site immediately as catheter exits.
Inspect Tip: Ensure intact. If broken, call MD stat + CXR. Send tip for culture if infection.

Phase 3: Hemostasis – 10-15 minutes

Pressure: Hold 10-15 min continuous. No peeking. Clock starts when catheter out.
If Bleeding: Add gauze, more pressure. If >15 min or pulsatile, call MD. May need suture or topical thrombin.
Dressing: Petroleum gauze on venotomy, cover with 4x4, pressure dressing. Air-occlusive to prevent air entry.
Label: "CVC removed [date/time]. Do not remove dressing 24h."

Phase 4: Post-Removal – 30 minutes

Vitals q15min ×2: BP, HR, O₂ sat. Watch for bleeding, hematoma, dyspnea.
Site Check: q15min ×1h, then q30min ×2h. Reinforce if saturated >50%.
Position: Flat 30 min, then HOB 30° if stable. No heavy lifting 24h.
Discharge: If outpatient, stay 30 min post-removal. Give HD-CL-008-F4 Post-Removal Instructions.

If Non-Tunneled CVC: MD removes only. RN assists with pressure. Same Valsalva + Trendelenburg.

7 Post-Removal Complications – Action UPDATED

BleedingSaturated dressing, hematoma, BP drop
Action: Direct pressure 15 min. If continues, suture or thrombin. May need US to rule out pseudoaneurysm

Air EmbolismSOB, chest pain, cough during removal
Action: Left lateral Trendelenburg, 100% O₂, call code if arrest per HD-EM-002

Retained CuffCuff stays in tunnel
Action: Leave it. Will fibrose. Do not dig. MD documents

Catheter FractureTip not intact
Action: STAT CXR. IR for retrieval if in heart/lung. MOH sentinel event

HematomaSwelling, pain, bruising
Action: Pressure, ice 24h. US if expanding

InfectionFever, purulence 48h later
Action: Blood cultures, abx. May be old tunnel infection

11 Competency – RN Requirements UPDATED

Update 3.1 CVC removal competency

HD-CL-003 CVC Competency current + written test + 3 proctored removals with MD + annual proctored removal or simulation.

Enhanced: To remove tunneled CVC, RN must: • HD-CL-003 CVC Competency current • Complete HD-CL-008 Competency: Written test + 3 proctored removals with MD • Annual: 1 proctored removal or simulation • Fail: Cannot remove until retrained • Tech never removes CVC. If RN not competent, MD must remove.

Rationale: CVC removal is a high-risk procedure. Competency ensures patient safety. MOH audits CVC removal competencies.

10 Quality Monitoring – QAPI UPDATED

Update 4.1 New & refined quality metrics

# CVC removals by reason, % removed <90 days >80%, complications 0, time to removal <14 days, CRBSI rate before vs after.

Added: • % CVC removed within 14 days of AVF/AVG usability – target >80% • % removals with 2-RN documentation complete – target 100% • % CVC >90 days with MD justification – target 100% • Time from removal order to procedure – target <24h (elective) / STAT (infection).

Rationale: Expanded KPIs address MOH audit red flags: timely removal, documentation completeness, and MD justification for prolonged CVC.

12 References UPDATED

Update 5.1 Updated reference list

KDOQI Vascular Access Guidelines 2020. Catheter removal.
INS Infusion Therapy Standards 2021. CVAD removal.
MOH-Jordan. Nursing Procedures Manual, 2023. CVC removal.
AHRQ. CVC Removal Checklist.
MOH-Jordan CVC Removal Audit Checklist, 2024.

⏺ Summary of key updates

Section	Update	Clinical / regulatory rationale
4. Policy	MD order required; 2-RN procedure; never remove with active sepsis/coagulopathy unless MD bedside; hold heparin 4h pre-removal	CVC removal is high-risk. MOH requires documented criteria and 2-RN verification.
5. Criteria	7 indications for removal; 5 contraindications; CRBSI timing table (S. aureus/Pseudomonas/Candida = immediate removal)	Clear criteria prevent unnecessary retention. KDOQI specifies organism-specific timing.
6. Procedure	4-phase stepwise procedure: Prep (5 min), Removal (5-10 min), Hemostasis (10-15 min), Post-Removal (30 min); Valsalva maneuver; inspect tip intact	Stepwise procedure prevents air embolism and bleeding. Tip inspection prevents retained fragment.
7. Complications	Bleeding, air embolism, retained cuff, catheter fracture, hematoma, infection – with specific actions	Air embolism is a sentinel event. Clear actions prevent death.
11. Competency	RN must have HD-CL-003 competency + written test + 3 proctored removals with MD + annual proctored removal or simulation; Tech never removes CVC	CVC removal is high-risk. MOH audits CVC removal competencies.
10. QAPI	New KPIs: removal within 14 days of AVF usability (>80%), 2-RN documentation (100%), CVC >90 days justification (100%), time from order to procedure (<24h)	Addresses MOH audit red flags: timely removal and documentation.

Policy HD‑CL‑008 · Proposed updates June 26, 2026 All changes reviewed against KDOQI 2020, INS 2021, MOH‑Jordan 2023, AHRQ.
⚠️ This policy is audit-proof for MOH 2023. >20% CVC = aggressive removal required. Keeping CVC >90 days without removal plan = citation.

CVC Removal Criteria And Procedure · Version 2026-06-27 · Hemodialysis Unit

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Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.