This month, Sandy Sundquist Beauman covers the vital topic of infection prevention. This blog entry is part one of two due to the extensive content on this important subject. In part one she covers infection prevention from a port access and care perspective.
Over the last several years, there has been a focus on infection prevention in hospitalized patients. The Institute for Healthcare Improvement (IHI) began discussing and leading the way toward development of several initiatives to decrease hospital-associated complications, primarily in adult patients in the late 1990’s. Now, there are “bundles” to decrease infections from various causes like surgical site infection, central line infection, ventilator related pneumonia and others. Many of these measures were not applicable or appropriate to the neonatal population.
However, recognizing an opportunity to improve for the benefit of the patient and facing financial penalties for the complications, many experts in the neonatal field have been working to create appropriate bundles for this population.
Bundles are made up of a collection of evidence-based, established practices. To quote an IHI article defining “bundles,” “The power of a bundle comes from the body of science behind it and the method of execution: with complete consistency. It’s not that the changes in a bundle are new; they’re well established best practices, but they’re often not performed uniformly, making treatment unreliable, at times idiosyncratic. A bundle ties the changes together into a package of interventions that people know must be followed for every patient, every single time.” (http://www.ihi.org/knowledge/Pages/ImprovementStories/WhatIsaBundle.aspx) Often, no single practice in the bundle has been shown to be any more or less effective than another and when performed together, lead to better outcomes. In many situations, it has been shown that simply consistency in practice makes all the difference.
Some key interventions included in central line associated blood stream infection (CLABSI) prevention bundles are discussed here.
Handwashing appropriately and use of clean gloves is, of course, one of the most basic infection prevention measures (O’Grady et al, 2011). Sometimes, in our attention to more involved measures, this basic one is minimized or overlooked. Often, it isn’t that folks aren’t washing their hands but may be shortening the recommended handwashing time, not using hand gel appropriately and other minor lapses that can still lead to the same outcome – contamination of the patient or device leading to infection.
Two other general areas of central line infection improvement are port care and IV tubing changes. The Cochrane Review analyzed five trials (Ainsworth et al, 2008). This meta-analysis showed no difference in risk of systemic infection between a percutaneously inserted central venous catheter or peripheral cannula IV. This is perhaps important in order to impact overall nosocomial infection rates. It may be wise to apply practices intended to decrease central line infection rates to the use of peripheral IVs as well. Port care and line access will be discussed here.
Port care/line access:
Closed systems are recommended to decrease catheter-related infections (O’Grady et al, 2011). The frequent access of infusion devices that is necessary in the NICU may well lead to the increased rate sometimes seen. Closed ports are available as positive flush, negative flush or neutral flush. There has been some observation that positive flush devices may lead to an increase in infection rates although there has never been a well-designed study to show this (www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm220459.htm). Reports have been made regarding an increase in infection rates with the use of these devices in certain facilities. What is unknown in these reports is what other practices may have changed or may not have been ideal. Nevertheless, there is a general concern about positive flush devices and the Society for Healthcare Epidemiologists of America and Infectious Disease Society of America recommend against the use of the positive flush device (http://www.jstor.org/stable/10.1086/591059). As for choice of the appropriate devices, some measures important to evaluate are discussed in an article by Hadaway & Richardson (2010). This is a helpful reference if you are in the process of evaluating closed flush devices. As might be expected, the fluid pathway is important. The more tortuous the fluid pathway, the more likely bacteria will collect in those areas.
Another important point is to focus on simply decreasing the number of connections and access points in an infusion line(O’Grady et al, 2011). Configuring the lines consistently helps to decrease unnecessary connections as well as assisting in supply availability.
Having considered all of these points, cleansing of the access port prior to access is the next consideration. Alcohol, chlorhexidine gluconate (CHG) and povidone-iodine are recommended by the CDC for port cleansing (O’Grady et al, 2011). Pratt et al (2007) recommend CHG for port cleansing. They recommend a 30 second swabbing period WITH friction and that the solution be allowed to dry. CHG is available in a 2% solution with 70% isopropyl alcohol and in a 4% solution without alcohol. The solution without alcohol does not dry. Therefore, in order to achieve drying, the solution with alcohol must be used. Experience shows, however, that this drying time is quite extended, maybe as long as 2 to 3 minutes. From a practical standpoint, if it takes too long for the drying to occur, the connection is made before it is dry! Additionally, there are reports that when CHG is used for cleansing these ports, it may become sticky rather than dry resulting in a permanent attachment of the syringe or tubing! Because of this experience, some units have abandoned the use of CHG for port cleansing. Therefore, consideration of using povidone-iodine or alcohol might be preferred. No studies could be located regarding use of povidone-iodine for port cleansing prior to access, however, it is one of the recommended solutions in the CDC guidelines (O’Grady et al, 2011).
Alcohol has been used to clean ports for many years. The technique of port cleansing with any solution is important but it may be that the friction used while cleansing the port is more important than the solution. Certainly, alcohol pads are readily available and fit nicely over the port to facilitate a proper cleansing. However, this may lead to cleansing of the outside edges of the port and not the area where the syringe will be attached!
Recommendations for timing of the cleansing vary from 10 seconds to 30 seconds. Kaler & Chinn (2007) performed a study in which alcohol was used to cleanse various types of ports. The ports were cleansed for 15 seconds using friction and allowed to dry. All types of ports were effectively disinfected using this technique. Sannoh et al (2010) report on a multimodal approach to hub care that resulted in a significant decrease in central line infections in a neonatal population. They used a 10 second scrub time with 2% CHG in 70% isopropyl alcohol for 10 seconds and allowed to dry for 30 seconds. This study just evaluated CLABSI rates for various types of lines but did not evaluate the scrub time specifically i.e. culture the hubs themselves to determine a decrease in bacteria. Some believe that if the protocol is to cleanse for 30 seconds, clinicians will make it at least 15 seconds! Extending that time too much, though, leads to shortcuts by busy clinicians, simply in the interest of delivering care to their patients efficiently. Making the time realistic and then auditing and enforcing may lead to better compliance.
Recently, a cap has been created that sits over the port and is impregnated with alcohol. This port cap has been reported to be instrumental in decreasing infections in several experiences (Sweet et al, 2012, Wright et al 2013, Wirtschafter et al poster presentation, 2012, Linford et al, poster presentation, 2012, Alasmari et al, poster presentation, 2012). Instructions on the use of the port cap, called the CurosÒ cap, indicate that it should be in place for at least 3 minutes and up to 7 days for effectiveness (http://www.curos.com/wp-content/uploads/Curos-Directions-For-Use.pdf). Manufacturer instructions do not include whether to prep the port after removal of the cap and before connecting tubing or syringe. This practice varies amongst users. Some consider the port sufficiently cleansed after removing the cap and others still require the port prepping as required otherwise. One of the reasons for continuing the requirement for the port cleansing is that there are some ports, due to their configuration, where the cap will not fit properly. If the habit of cleansing the port is not continued, perhaps this would lead to poor or absent cleansing when no cap is present. Therefore, many continue to require the cleansing with alcohol prior to attaching tubing or a syringe.
Several practices related to port access and cleansing to improve infusion related infection prevention have been discussed. As mentioned earlier, another major area to be discussed is related to IV tubing changes. This will be the topic for the blog next month. Hope to see you there!
1. O’Grady NP, et al. CDC Guidelines for the prevention of intravascular catheter-related infections, 2011. http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html.
2. Ainsworth S, Clerihew L, McGuire W. Percutaneous central venous catheters versus peripheral cannulae for delivery of parenteral nutrition in neonates. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004219. DOI: 10.1002/14651858.CD004219.pub3.
3. Hadaway L, Richardson D. Needleless connectors: A primer on terminology. Journal of Infusion Nursing. 2010; 33(1):22-31.
4. Kaler W, Chinn R. Successful disinfection of needleless access ports: a matter of time and friction. Journal of the Association for Vascular Access, 2007; 12(3):140-142.
5. Sannoh S, Clones B, Munoz J, Montecalvo M, Parvez B. A multimodal approach to central venous catheter hub care can decrease catheter-related bloodstream infection. American Journal of Infection Control. 2010; 38:424-429.
6. Sweet MA, Cumpston A, Briggs F, Craig M, Hamadani M. Impact of alcohol-impreganted port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit. American Journal of Infection Control. 2012; 40(10):931-934.
7. Wright M-O, Tropp J, Shora DM, Dillon-Grant M, Peterson K, Boehm S, Robicsek A, Peterson LA. Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infections. American Journal of Infection Control. 2013; 41:33-38.