Placing a needleless connector on all VAD hubs and then attaching a continuous infusion system has become common practice. But why do we think this is necessary? What benefit, if any, is offered by this practice? It has long been a point of concern for me. Before needleless connectors were introduced, the only option was to place a needle on the end of the IV administration set and insert this needle through the solid covering on the injection cap. Yes I am aware that this practice tells you how long I have been doing this!! There were concerns about having a needle residing inside the injection cap for extended periods including breakage of the needle inside the catheter lumen, having the needle piston into or out of the injection cap, the risk of infection, and the risk of needlestick injury to healthcare workers. So this practice was limited to only short-term intermittent infusions, usually over 30-60 minutes. All continuous infusions were connected by a direct hub-to-hub luer locking mechanism. The introduction of the needleless connectors eliminated the use of needles and the risk associated with them. But these connectors were designed for intermittent use. So why has it become common practice for their use in a continuous infusion? The most common reason I have been given is avoid opening the catheter lumen when it is time to change the administration set. But, that reason does not stand up to the CDC guidelines stating that the needleless connector should be changed at the same interval as the administration set. So the lumen must be opened to change both the connector and set simultaneously. The presence of a needleless connector inside a continuous system allows for questionable practice of stopping the infusion when the patient wants to ambulate, or shower, or other activity. This means an increase in manipulation of the catheter hub, and a possible increased risk of contamination and infection. This issue is more applicable to hospitalized patients as most infusions in alternative settings are intermittent rather than continuous. The needleless connector in a continuous infusion adds an unnecessary device (this means added costs); they are a known source of infection; and they do nothing to enhance or alter the fluid flow in any way. The connector was designed for the sole purpose of eliminating the needle and the risk of needlestick injury. So I see no reason for using them in a continuous infusion system. I know that many other professionals disagree with me on this, but we need evidence. The 2014 SHEA Compendium CLABSI chapter includes this practice as an unresolved issue stating, “No data are available regarding their use with continuous infusions.” So just like everything, we need more studies! I am hoping drawing attention to this issue will spur the interest of researchers. The standard of care for all central vascular access devices (CVAD) is to know the anatomical tip location before infusion therapy is given through the catheter. A chest radiograph (CXR) to determine anatomical location of the catheter tip has long been the “gold standard” following placement of each CVAD. Nurses now insert the majority of PICCs, usually at the bedside or in a procedure room, as this is the most practical and cost effective process. Additionally the practice of nurse specialist is expanding to include insertion of other percutaneous centrally inserted catheters. Although many PICCs now use electrocardiograms (ECG) to determine tip location, there will always be patients in need of a CXR to confirm a CVAD/PICC tip location. The nurse inserting the CVAD/PICC and assessing the CXR for tip position enhances the quality of care because timely results are known without delays in infusion therapy. This process also provides more documentation for appropriate information and management surrounding the insertion procedure. To enhance patient flow through the system and reduce costs of care, avoiding delays in treatment is paramount. Waiting on the radiologist or other physician for the “official” reading delays the delivery of critical fluids and medications. Requiring the nurse inserter to confirm tip location with a radiologist or other physician also delays infusion therapy. In many facilities, PICC insertion could be limited to the times when the radiologist is available. Or, the catheter is inserted, but cannot be used for infusion until a radiologist is available to assess the location and “release” it for use. Inadequate information about tip location from Radiology creates an unsafe situation for the patient. According to the Infusion Nursing Standards of Practice, nursing staff must know the specific anatomical location BEFORE infusion therapy is started (INS, 2006, S42-S43). Verbal information from Radiology can be vague and unacceptable such as, “Line is in good position” or “It is okay to use”. These statements do not convey the specific anatomic location and the written report may not be available for hours, even days. A nurse inserting CVAD/PICCs should have the knowledge of chest anatomy and physiology of blood flow. Also a nurse inserting a PICC can have the knowledge and skill to assess a CXR for correct catheter tip location. It is important to note that this is not the same as “reading a CXR.” The nurse-inserter is correlating the patient’s anatomy on the CXR to the CVAD/PICC tip location and position. Reading the CXR is medical practice for diagnostic purposes as it involves the complete assessment for all pathophysiological changes in the chest such as pneumonia or a pneumothorax or tumor. Confirmation of PICC tip location can now be done by assessing ECG. Competent nurses in many areas of clinical practice assess ECG rhythms to validate clinical assessment parameters and provide treatment based on that assessment. Likewise, an educated nurse with documented competency is qualified to assess the CVAD/PICC tip position by ECG or CXR assessment. The next question then becomes can the nurse-inserter provide instruction to the staff nurse that the CVAD/PICC is correctly positioned and can be used for infusion. In my opinion, if there is documented competency and well written and approved policy and procedures, then assessing a CXR and telling the staff nurse when it is acceptable for infusion is within the scope of practice for nurses who are inserting CVAD/PICCs. It is imperative to know the position of the board of nursing in the state where you practice about these issues. Most, but not all, state boards of nursing now use the scope of practice decision tree with questions for the nurse and employer to answer scope of practice questions. Principles of radiology, the process for assessing a CXR, and the legal issues of this practice are thoroughly discussed in our online course – Chest Radiograph Assessment and Central Vascular Access Devices. Learn more about assessing CXR from this online course, which includes a sample policy and procedure and competency assessment forms. By passing this online course, you also earn 4 CRNI recertification units! Recently, a new set of guidelines was released by the Society for Healthcare Epidemiology of America. – Strategies to Prevent Central Line Associated Bloodstream Infection in Acute Care Hospitals: 2014 Update. Download a free copy here. I was honored to serve on the committee to revise this document, originally written in 2008. Many aspects of catheter insertion and maintenance are now supported by stronger evidence such a routine bathing with chlorhexidine and nurse-to-patient ratios in ICU. Other aspects of care not previously addressed are included such as a recommendation for a vigorous mechanical scrub of a needleless connector for a minimum of 5 seconds. Other highlighted information remains unanswered by evidence including a statement about no evidence for using a needleless connector in an infusion system set up for continuous infusion of fluids. There is a new section on examples of implementation strategies, based on the 4 components of implementation science – engage, educate, execute, and evaluate. I was actually surprised at the number of studies about education for central venous catheter insertion. Over the past 10 years, we have seen an enormous amount of consideration and resources dedicated to reducing bloodstream infections caused by central venous catheters. You could be feeling overwhelmed but don’t ignore this information yet. Vascular catheter associated infection continues to be listed as a hospital acquired condition, meaning that your hospital receives no payment to treat this complication. Additionally, the Center for Medicare and Medicaid Services continue to expand their application of value-based purchasing as a result of the Affordable Care Act. In 2012, a CMS report used many forms of data analysis to reveal that patients with a vascular catheter associated infection have a 33% increased risk of being re-admitted as an inpatient. And hospital readmission is another cause of reduced payments to hospitals. So now is definitely not the time to let down your guard. On July 24th, I will lead a discussion of the changes in this updated document and address any questions you may have about the contents. This is a video conference presentation scheduled to begin at 1 pm ET. This presentation will be repeated on August 21st at 3 pm ET. Visit here to register for the video conference. Download the final document above and be prepared to discuss your questions and concerns about its content. |
Author: Lynn HadawayLynn Hadaway is an international thought leader in infusion therapy and vascular access, having been in this practice for more than 40 years. Her experience comes from hospital-based infusion teams, device manufacturers, and continuing education services. Her journal and textbook publications are extensive. She also maintains board certification in infusion nursing (CRNI) and nursing professional development (RN-BC). Categories
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May 2019
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