If you have an interest in patient safety and understand the impact of real life stories this is the video for you.
It is essential that an aseptic technique is followed during the placement of a peripheral IV device. This approach will ensure contamination and potential infection are avoided. However, to what extent do we need to complicate what should be an easy to replicate straightforward procedure.
When considering asepsis during straightforward IV procedures we should focus on extraluminal and intraluminal contamination prevention. During the preparation and completion of a simple IV procedure such as peripheral IV insertion the protection of points of potential contamination will prevent infection. Should we complicate the approach to asepsis or should we simply ensure clinicians understand how to protect the patient from touch contamination? The following FAQ may help with further discussion:
- Is a sterile drape required during placement of peripheral IV devices? To answer this question we should reconsider what function the sterile drape plays towards infection prevention during placement of peripheral IV devices. I propose that the sterile drape place underneath a patients arm during device placement play no role in the prevention of infection. The use of a sterile drape simply adds further steps to a straightforward IV procedure.
- Once a drug is drawn into a syringe how do you protect the luer connector? First of all thank you for identifying that it is vital to protect the luer connector which in turn will prevent intraluminal contamination. Simple! You can achieve lure protection from a number of proprietary products. However, one simple approach is the use of the syringe wrapper to protect the luer connector.
- Sterile or non sterile gloves? The simple answer to this question is another question! If your gloves are non sterile they must not come into direct contact with sterile or cleaned parts during the procedure. If touch cannot be avoided then sterile gloves will be required. However, the sterile gloves themselves are prone to inadvertent touch contamination. Complicated! My advice would be to try and keep it simple; wear non sterile gloves and avoid direct or indirect contamination of intraluminal or extralumial sites.
It is essential that we spread the word and ensure all clinicians understand the role of intraluminal and extraluminal protection during IV procedures. More information is available at www.ivprotected.com
In a recent article cited on IVTEAM concerned with PICC associated upper extremity deep venous thrombosis the authors present an insight into how a patient initially presents with a suspected upper extremity DVT. They discuss Upper extremity DVT and present some excellent ultrasound images of the case in question. However, they fail to describe or acknowledge PICC gauge size or tip location. The text hints that the tip location may have been suboptimal, stating “Long-axis ultrasonographic evaluation of the axillary and subclavian veins near the PICC line tip revealed deep venous thrombosis of both the axillary and subclavian veins” (Rosen, Chang, Kaufman, Soderman, and Riley 2012).
It is vital that when writing about PICC associated upper extremity deep venous thrombosis authors include a section on issues such as PICC gauge size, type of PICC and elements on PICC design. Furthermore, authors should describe the peripheral vessel used for access and the tip location of the PICC when the patient presents with a suspected upper extremity DVT.
Finally, upper extremity DVT should not be simply be attributed to the presence of a PICC. We must look beyond the PICC. If gauge size or tip location are suboptimal then these are the likely factors that may have contributed to upper DVT formation.
Rosen, T., Chang, B., Kaufman, M., Soderman, M. and Riley, D.C. (2012) Emergency department diagnosis of upper extremity deep venous thrombosis using bedside ultrasonography. Critical Ultrasound Journal. 4(1), p.4.
Here in the UK we are in the fortunate position to have a number of excellent vascular access and infusion therapy conferences from which to choose. Also, we have access to international conferences such as the recent WoCoVa 2012. One particular conference that I am looking forward to attending (and speaking) is the IPS IV Forum Conference in Old Trafford Stadium, Manchester on the 29th November 2012.
The day will address areas such as:
- Contamination issues preparing IV medications
- Health Technology Assessment
- Evidence in Practice
- Shoe leather surveillance
- Matching Michigan in Neonates
- Implementing an OPAT service
- EU sharps directive – implications for practice
Benner (1984) describes the “growing edges of knowledge” demonstrating that we can “preserve and extend knowledge”. Benner also introduces the concepts of ‘know how’ and ‘know that’. She describes how you can know how without knowing that. Knowing how is is described as the completion of a task; for example knowing how to give an injection. The ‘knowing that’ element relates to the action of the drug, side effects, interactions etc. Both elements of vital for safe vascular access and infusion therapy.
One concept that may help to take forward how we teach vascular access and infusion therapy are elements known as ‘background’ and ‘foreground’ knowledge. Straus (2011:17) describes that “clinical practice demands the use of large amounts of both background and foreground knowledge”. Background knowledge acts as an ‘archive’. The ‘imaginative’ and ‘enquiring‘ foreground knowledge moves the clinician into the realms of knowledgeable doer (UKCC 1986).
When teaching, background knowledge may be illustrated by the type of questions that are asked by the learners. Those with little experience will depend upon a greater number of background questions. The answers to these questions help to frame the issue within an expected knowledge base. Examples would include normal blood pressure range or glucose levels in the blood. Once a person begins to fill the background knowledge component they move into foreground questioning. Without this opportunity to enquire, further learning would be stifled.
These concepts of adequately prepared learners is vital if we are to continue to build upon existing knowledge. As Fisher, Ross and Grant (2010:23) suggest “lack of background knowledge can have an impact on their ability to ask questions and wonder—both key components of inquiry”. Once background knowledge is built and activated it can be combined with foreground knowledge. It is this ability to process knowledge in this efficient manner that helps knowledge to be integrated into practice. When we teach vascular access and infusion therapy it is important that we identify both ‘background’ and ‘foreground’ learning elements.
I regularly see skill sessions on topics such as cannulation full to the brim with ‘background’ components. These main skill sections include topics such as cleaning the skin, skin tension, angle of insertion, first and second flashback etc. This ‘background’ experience allows the practitioner to learn cannulation. It is at this point that we may even describe the learner as competent! However, if we visit the concept of ‘foreground’ knowledge we begin to acknowledge the intricate components of skill completion that transports a practitioner beyond the level of novice. We can begin to understand the importance of foreground knowledge. Placing a vascular access device within a vein is only one component of successful vascular access. If we are to improve the vascular access experience for our patients we must extend the foreground knowledge of our learners. Foreground knowledge offers a rationale for our actions. For example, foreground knowledge on disinfecting the skin moves the learner beyond skin cleansing; taking them to knowing how and why we clean the skin and what is likely to happen if we fail to complete the task to the expected standard.
Background knowledge is essential; foreground knowledge brings understanding and may increases procedural compliance.
BENNER, Patricia E. (1984). From novice to expert: Excellence and power in clinical nursing practice. Addison-Wesley.
FISHER, D., ROSS, D. and GRANT, M., 2010. Building Background Knowledge. The Science Teacher, 77(1), 23-26.
STRAUS, Sharon E. (2011). Evidence-based medicine: How to practice and teach it. Edinburgh, Elsevier Churchill Livingstone.
UKCC – UNITED KINGDOM CENTRAL COUNCIL FOR NURSING, MIDWIFERY AND HEALTH VISITING (1986). Project 2000: A new preparation for practice UKCC. London.
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How many times have you heard that arterial lines do not become infected. In a recent discussion I was informed that the reason these types of catheters are not a source of infection is that the blood flow is too fast; bacteria are not strong enough to hang on! Is this true?
To offer an insight into a possible answer to this question I decided to reverse the question. Which practices associated with arterial lines may result in an increased risk of contamination? I’m sure you can think of many. The main issues that I am concerned with are that arterial lines remain in place for many days, I assume they are not immune to biofilm formation (or are they) and the most important factor is that they are often accessed multiple times for blood sampling.
I’m beginning to think that the comment that arterial lines do not become infected is an urban myth. What about the literature? Makii, Kluger and Crinch (2006) Completed a systematic review of 200 published prospective studies that examined the risk of bloodstream infection in adults with different intravascular devices. Maki et al (2006) present the data in a variety of forms and I recommend that you read the full study. However, for the purpose of this discussion the arterial catheter blood stream infection rate per thousand catheter days is 1.3 (based on studies requiring microbial concordance between catheter and blood cultures).
Finally, we have an answer. Arterial lines can and do become infected. However, the opposite is also true, arterial line bacteraemia can be prevented.
MAKI, D.G, KLUGER, D.M. and CRINCH, C.J. (2006) The Risk of Bloodstream Infection in Adults With Different Intravascular Devices: A Systematic Review of 200 Published Prospective Studies. Mayo Clinic Proceedings. 81(9), 1159-1171.
Over recent years we has seen many initiatives that have assisted with Central Line Associated Blood Stream Infection (CLABSI) prevention. In particular the development of bundles has provided a format for consistent ‘infection prevention’ behaviour during vascular access device insertion and subsequent care. However, authors rarely make clear one particular message from the implementation of the bundle. I personally believe that the main focus for each bundle should be concerned with the prevention of ‘extraluminal’ and ‘intraluminal’ contamination.
For more information of ‘extraluminal’ and ‘intraluminal’ contamination visit IVprotected.com
If clinical staff fully understand the risks associated with ‘extraluminal’ and ‘intraluminal’ contamination they can begin to use products and function in a way that prevents contamination. It is vital that we review our practice (and that of others) so that IVs are protected. Simple approaches such as the use of medicated IV dressings, checking that dressings are intact or reviewing practice routines such as the length of time required to clean the skin (30 seconds) or scrub the hub (15 seconds) are easily introduced into practice..
Infection prevention associated with vascular access does not have to be complicated. The role of hand hygiene dominates infection prevention practice. The simple addition of ‘extraluminal’ and ‘intraluminal’ protection offers a simple yet effective vascular access infection prevention approach.
For more information of ‘extraluminal’ and ‘intraluminal’ contamination visit IVprotected.com
Historically, the idea of success in vascular access was defined by issues such as number of attempts at insertion or infection rates. It is important that these measures continue. However, it is now time that we also look at additional measures of success. These may include:
- Phlebitis rates
- Occlusion rates
- Dislodgement rates
Overall, the question we should ask ourselves is ‘did the device reach your expected outcome’. In other words, did the device reach its intended dwell time. This approach ensures a preventative approach it adopted for vascular access that extends beyond traditional infection prevention. If we take phlebitis as an example; in an unpublished review phlebitis rates changed from 5.1% to 2.2%.
The details of the review compared 1078 peripheral IV removals in 2005 with 846 removals in 2011. The review concentrated on the incidence of phlebitis. When converted to percentages the phlebitis rate for 2005 was 5.1%; in 2011 the rate was 2.2%. Not only did the percentage of phlebitis rates vary, it was also found that the severity of phlebitis reduced in 2011. In 2005 Visual Infusion Phlebitis (VIP) scores ranged between two and three (one incidence of four). However, in 2011 the highest recorded phlebitis score was two using the Visual Infusion Phlebitis score.
What are your expectations of an IV dressing? I’m sure we could all list properties such as sterile, aid site observation, ensure fixation, easy to apply and be robust enough to withstand the rigours of everyday vascular access. What about the issue of removal? It is vital that dressings are easy to remove and definitely do not require the use of sharp instruments near to the vascular access device. Using IV dressings as intended usually poses little problem for the person completing the dressing change. What about when a sandwich technique is used. The sandwich technique involves using two opposing IV dressings to sandwich the vascular access device between the conjoined adhesive of both dressings. This technique will inevitably pose a problem for the clinician when the dressing needs to be changed. Excessive catheter movement, potential dislodgement, contamination and the possibility of damage if a sharp implement is involved are far too great a risk to take when the manufacturers recommended dressing technique has been used successfully time and time again.