Infection Control

Resource Vol. 4 No.2 Prevention Strateg ies for IC Practitioners and Professional Nurses

In this issue ntravascular catheters are indispensable in modern-day medical practice. Although these Flushing vascular Itypes of catheters provide necessary vascular access, they can put patients at risk for local and ng Educ ui at systemic infectious complications, including local access catheters: n io ti n site infection, catheter-related bloodstream infections n o (CRBSI), septic thrombophlebitis, endocarditis, and C other metastatic infections. CRBSI is the most life Risks for infection threatening of all healthcare-acquired infections and accounts for significant medical costs, estimated at CECE nd Nurses transmission ontrol Professionals A ion C approximately $2.3-billion annually. The introduction For Infect of microorganisms (and biofilm) during insertion and GE 7 use of vascular catheters is ubiquitous. Effective skin by Lynn Hadaway, RN, C, MEd, CRNI SEE PA antiseptics and application techniques remove most but not all organisms. t has long been accepted that the process Catheter-flushing procedures that result in a sudden onset of fever and chills could be causing the release of flushing vascular access catheters is a of cell clusters from biofilm. Catheter flushing is primary method for maintaining catheter Approximately 87% of much more than injecting some fluid through the patency, although there is very little clini- catheter lumen. Clinical outcomes depend upon the calI research on the practice. Ideally, the catheter bloodstream infections entire system working together. In her article, Ms. should flush freely without offering any resis- Hadaway discusses infection prevention techniques, are associated with the including proper catheter flushing techniques with tance to the fluid flow. All vascular access devices single-use flushing containers, adequate cleaning of should yield positive blood return when aspi- the needleless surface before each connection, and rated and are considered to be non-functioning presence of some type of careful attention to hand hygiene. when blood return cannot be obtained. intravascular device. VISIT US ONLINE Catheter-related bloodstream infections Infection Control Resource (CRBSI) take a very large toll on clinical and is now online at financial resources in U.S. healthcare. Ap- infusate-related bloodstream infections. The www.infectioncontrolresource.org proximately 87% of bloodstream infections You can now get your FREE CE imemdiately 100,000 Lives Campaign from the Institute for by taking the test online at are associated with the presence of some type Healthcare Improvement, the National Patient www.saxetesting.com of intravascular device.1 CRBSI is the most Safety Goals from the Joint Commission for life-threatening of all healthcare-acquired in- Accreditation of Healthcare Organizations, the Advisory Board fections and accounts for significant medical Committee to Reduce Infection Deaths, the

Gwen Beiningen, RN, MS, CIC costs, with total costs estimated as high as $2.3- SAVE That Line! campaign from the Association Infection Control Coordinator billion annually.2 for Vascular Access, and mandates from many Sioux Valley Hospitals & Health Systems Sioux Falls, SD The connection between bloodstream in- state legislatures for mandatory public report-

Gail Bennett, RN, MSN, CIC fections and flushing procedures is becoming ing of healthcare-acquired infections are actively Associate Executive Director, a serious area of concern. The technology of promoting attention to this problem among ICP Associates, Rome, GA vascular catheters, pieces added on to the cath- hospital administrators, all levels of healthcare Nancy Bjerke, RN, MPH, CIC Infection Control Associates eter, flush-solution containers, syringe design, workers, and patients and their families. San Antonio, TX and techniques being used must work together To understand how flushing procedures af- Barbara DeBaun, RN, MSN, CIC effectively as a system. Without a systems ap- fect the risk of bloodstream infections we must Director, Infection Control California Pacific Medical Center, San Francisco, CA proach, you will find that changing one piece first explore the major cause of such infections:

Elaine Flanagan, BSN, MSA, CIC may not alter your problems with catheter pa- biofilm. Manager Epidemiology tency, and the risk of infections associated with Detroit Medical Center, Detroit, MI flushing procedures will be greater. Catheters and biofilm Susan Slavish, RN, BSN, MPH, CIC Infection Control, Queen’s Medical Center Zero tolerance for healthcare-acquired in- The introduction of microorganisms during Honolulu, HI fections is now the goal, with several national insertion and use of vascular catheters is ubiq- Barbara Soule, RN, MPH, CIC initiatives focused on reducing or eliminat- uitous. As the catheter passes through the skin Consultant, Joint Commission Resources Oakbrooke, IL ing these infections, including catheter- and during insertion, it is exposed to organisms in ResourInfectionce Control

the deep layers of the epidermis. About 80% mg of EDTA in 1 mL distilled water. Begin- of resident organisms reside in the top five ning on day 3, catheters in all groups were layers of the epidermis, and the remaining According to the flushed once every 24 hours with the respec- 20% live in biofilm in deep epidermal layers, tive solutions for 5 days. Quantitative blood sebaceous glands, and hair follicles.1 Effec- Infusion Nursing cultures taken from all 18 rabbits on day 3 tive skin antiseptics and application tech- showed S epidermidis. For those undergo- niques remove most but not all organisms, Standards of Practice, ing vancomycin-heparin flushes, 3 out of 5 allowing some to attach to the catheter on showed complete resolution of bacteremia by insertion. In addition, as the catheter hub is there are two purposes day 7; those undergoing minocycline-EDTA used for medication administration, flush- flushes had 100% resolution of the bactere- ing, tubing and cap changes, and blood sam- for flushing a catheter: mia by day 7. pling, other organisms enter and cling to the In-vitro tests by Shah et al.7 inoculated catheter’s internal wall. Catheters that have to maintain catheter catheters with broths growing S aureus, S been used for a few days have more biofilm epidermidis, Pseudomonas aeruginosa, En- on the external wall, while those indwelling patency and to prevent terococcus faecalis, and C albicans, and then for longer periods have more biofilm on the treated them with either a heparin flush of internal wall.1 contact between 5000 U/mL or a taurolidine (1.35% [wt/ When organisms simply touch the cath- vol]) and citrate (2.61% [wt/vol]) solution eter surface, adhesive materials are produced incompatible fluids and flush. The inoculated organisms grew in the that firmly attach them to the catheter wall. heparin-treated catheters while the catheters Once the catheter enters the bloodstream, a medications. treated with taurolidine citrate did not sup- conditioning process begins with proteins port growth of these organisms. also attaching to the catheter surface, fol- Raad et al.8 performed an in-vitro study of lowed by platelets and white blood cells. duction methods and were then correlated to catheter segments plus 54 colonized catheter Within five minutes, the amount of attached the clinical findings. The presence of central tips removed from patients. They also dem- proteins is about equal to the amount in the venous catheters and infusion of parenteral onstrated that heparin can support microbial circulating blood. The normal coagulation nutrition were the clinical factors associated growth in fresh and mature biofilm. process causes the development of a fibrin- with laboratory-developed biofilm. A recent in-vitro study by Shanks et al.9 ous layer on the catheter that is commonly Many studies have shown heparin to sup- examined the mechanisms by which heparin a depth of 1 millimeter within 24 hours of port the growth of organisms both in solu- stimulates the growth of S aureus biofilm. catheter insertion.1 tion and in biofilm. For example, Root et al.5 The findings suggested that heparin does not After attachment to the catheter’s inter- removed a tunneled central venous catheter, increase the attachment of organisms to the nal and external surfaces, organisms grow growing Staphylococcus epidermidis, from a catheter surface, but it does promote cell-cell and multiply to form cell clusters or mush- septic bone-marrow transplant patient and interactions, causing growth of biofilm. room-shaped colonies while also produc- subjected the catheter to numerous labora- ing an exopolymer substance or glycocalyx, tory tests to determine what solution would Catheter-flushing protocols a self-protecting slime. The biofilm surface inhibit the organism’s growth. Catheter seg- Cells embedded in biofilm are known is uneven and is composed of about 10% to ments were incubated in four separate solu- as sessile, while free-floating cells are called 25% organism cells, with the remaining 75% tions: disodium ethylenediaminetetraacetic planktonic cells. Cells, individually or in to 90% being the slime.1 The biofilm con- acid (EDTA) 20 mg/mL, heparin 10 U/mL, clumps or clusters, break off from biofilm tains channels that allow essential nutrients vancomycin 6.7 µg/mL, and a combina- and become planktonic. This mechanism is and oxygen to reach the cells within and the tion of those same doses of vancomycin thought to be the most important aspect of waste of cell metabolism to flow out. Biofilm and heparin. Quantification of the biofilm converting a biofilm to a clinical infection.

can also trap various particles such as miner- growth in the four solutions showed >8 log10 Catheter-flushing procedures that result als, red blood cells, and platelets.3 colony-forming units/mL at 24 hours in the in a sudden onset of fever and chills could Research now indicates that glucose in- heparin-only solution, the largest growth for be causing the release of cell clusters from creases the growth of biofilm. In-vitro tests all four fluids. biofilm. by Shin et al.4 have shown that several Can- Raad et al.6 implanted catheters into According to the Infusion Nursing Stan- 2 dida species can easily grow in dextrose-con- jugular veins of rabbits; they then inoculated dards of Practice,10 there are two purposes taining broth. Non–C-albicans Candida spe- the catheters with S epidermidis and flushed for flushing a catheter: to maintain catheter cies grew more readily in the broth contain- them with only heparin for two days. The patency and to prevent contact between ing 8% dextrose, suggesting a connection rabbits were then randomly divided into incompatible fluids and medications. For between biofilm formation and candidemia three groups: five rabbits undergoing 0.5 maintaining catheter patency, 0.9% sodium in patients receiving parenteral nutrition. In mL flushes of heparin (100 U/mL); five un- chloride (normal saline) and heparinized this study, the isolates obtained from clini- dergoing 0.5 mL flushes of 3 mg vancomy- saline lock solution are commonly used. For cal specimens taken for diagnostic purposes cin in 100 U heparin; and eight undergoing preventing contact between incompatible were subjected to laboratory biofilm pro- 0.5 mL flushes of 3 mg minocycline and 30 fluids, 0.9% sodium chloride is used.

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The most common procedure is often called SASH‑—Saline, Administer medica- Practical approaches to tion, Saline, Heparin. The initial saline flush preventing infection is used to assess catheter patency. The nurse should pay careful attention to any degree Every time a catheter is flushed, there’s a risk When in constant use, they must be changed of infection. Lynn Hadaway gives Infection at the same time as IV administration sets. of resistance when flushing the catheter. The Control Resource some suggestions on reduc- When infusion therapy is given intermittently, saline-filled syringe used for flushing is also ing that risk. the needleless device must be changed at least once every seven days. used to aspirate for a positive blood return What is the relationship between catheter from the catheter, as this is the major factor lumen occlusion and bloodstream infection? What impact does patient activity have on reflux of blood into the catheter lumen? in assessing the proper function of the cath- After a catheter has been placed, plasma eter. Without a positive blood return upon proteins and platelets begin adhering to the Any time the catheter is compressed, the fluid aspiration, the catheter should be considered inner wall, producing a fibrin matrix. Intralu- used to lock the catheter will be forced into minal biofilm forms simultaneously with the the bloodstream. When the compression is to be non-functioning, and it requires fur- fibrin matrix, because microorganisms gain relieved, blood is pulled into the catheter ther assessment, diagnostics, or treatment entrance to the catheter lumen each time it lumen to fill the space vacated by the lock- before it is used. is manipulated. ing fluid. The volume of normal saline for catheter The opportunity for infection occurs at the Compression occurs with many types of cath- flushing ranges from 1 to 20 mL. For a short outset of catheter placement—for instance, eters. For instance, the muscles of the upper during insertion, blood is aspirated to confirm arm affect a PICC. Normal muscular contrac- peripheral catheter, 1 to 3 mL is most often the catheter’s location within a blood vessel. tion helps to move blood back to the heart used unless a vesicant or irritating drug re- In addition, brisk blood return is mandatory by compressing peripheral veins. If muscular quires a larger volume to adequately assess before each use of a central venous catheter, contraction is excessive, it can compress the as it’s one sign of patency and proper location. soft, flexible catheter inside the vein. Patients vein patency. For central venous catheters, 5 Each time the catheter is used to deliver a dose should be taught to avoid excessive, strenu- to 10 mL is most frequently used, and 20 mL of medication or to obtain a blood sample, ous activities while a PICC is in place. is preferred after obtaining a blood sample or when the administration set or needleless injection device is changed, microorganisms Patients sometimes develop a habit of from a central venous catheter. The Infusion and blood enter the lumen. Over time, the pinching or rolling external catheters (i.e., Nursing Standards of Practice recommends biofilm-fibrin combination can become thick twiddler’s syndrome), which can also cause catheter compression. a minimum flush volume equal to twice enough to partially or completely occlude the lumen. Patient activity and suboptimal flush- the internal volume of the catheter system, When catheters are inserted in the medial ing techniques can also cause whole blood to subclavian vein, pinch-off syndrome is a dis- which includes the catheter, extension set, reflux into the lumen and to clot. tinct possibility. The catheter can be com- and/or needleless injection system added to What can be done to reduce the incidence pressed between the clavicle and the first the catheter hub. of catheter occlusion? rib. Not only does this promote reflux into the lumen, but it also causes a great risk of Although the evidence linking heparin First and foremost, pay close attention to catheter fracture and embolization, because to biofilm growth is increasing, heparin still proper hand hygiene before each and every the bone movement exerts a scissor action remains the solution thought to prevent manipulation of the IV system. Don clean against the catheter. gloves immediately before touching the IV clots within the catheter. Heparin, includ- tubing, connectors, or catheter. Each time you What effect does heparin have on these ing formulations with preservatives, lacks must administer medication, use a new alco- issues of blood reflux? Is heparin still necessary to maintain catheter patency? antimicrobial activity.11 Heparin is frequently hol pad to scrub the connector surface for 10 to 15 seconds. Alcohol is a good disinfectant, omitted from the flushing procedure when This is a controversial issue, and we definitely but physical scrubbing reduces the level of need well-designed, randomized clinical trials the catheter or the type of needleless injec- contamination just as much as the disinfec- to address it. Heparin supports the growth of tion system has instructions stating that tant. For the SASH procedure, this means using biofilm, and there is growing concern about four alcohol pads, one before each of the four saline-only flush procedures can be used. the incidence of thrombocytopenia caused by steps in the procedure. exposure to small amounts of heparin. This procedure is commonly referred to as Reducing blood reflux requires attention to SAS. The practice of heparin flushing could Flushing solution may have no effect on lu- the syringe and awareness of the type of men occlusion when blood reflux is caused change when new flush solutions are com- needleless injection system in place. If you’re by mechanical actions such as catheter com- mercially available. flushing a catheter and not using a prefilled pression. Flushing technique may have more syringe designed to eliminate syringe-induced The concentration of heparin flush solu- impact on lumen patency when blood reflux reflux, don’t flush all the fluid from the is due to the type of needleless device. tion ranges from 10 to 100 units, although syringe; this will prevent the rubber gasket the smallest dose that will accomplish the on the plunger from being compressed and Our expanding knowledge of biofilm and then rebounding and promoting reflux into fibrin formation seems to indicate that the goal should be considered. The volume of so- the catheter lumen. Know the type of needle- ideal solution will be one that decreases the lution should be twice the internal volume of less injection device being used—negative, development of both substances. There are 3 the catheter system. For neonatal and pediat- positive, or neutral displacement—and use the many questions remaining to be answered, appropriate flushing technique after each IV yet it appears that an anticoagulant with ric patients, 1 U/mL may be chosen. Larger administration; this will reduce the amount of antimicrobial properties is needed. At pres- doses of 1000 or 5000 U/mL are often used blood left to reside in the catheter lumen. ent, in the USA, there is no commercially on hemodialysis catheters, although these available alternative to heparin-based flush- Needleless injection devices are known to ing solutions. large doses must be aspirated before cath- grow biofilm and cannot be used indefinitely. eter use to avoid systemic anticoagulation. Several in-vitro studies12-14 have reported that a significant amount of fluid will spill

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out of the catheter lumen after it is locked atitis C (HCV), human immunodeficiency with the heparin flush solution. At present, it virus (HIV), and malaria. is unknown what implications these studies Current DeBaun has reported on the problem of have for clinical practice; however, this leak- disease transmission with multidose vials.22 age of heparin from the catheter lumen into recommendations, There are additional published reports that the bloodstream should be considered when focus on catheter-flushing solutions and choosing the heparin concentration. This guidelines, and national disease transmission; for example, Silini et would be especially important when a hemo- al.23 reported on the transmission of HCV dialysis catheter is locked with large concen- standards of practice in a hematology unit. From August 1997 to trations of heparin. It would be possible for August 1998, there were 13 cases of HCV this leakage to affect coagulation times. strongly favor the use of seroconversion among 294 patients admit- Several drugs are incompatible with ted to this nursing unit. Eleven of the 13 pa- normal saline and require flushing with 5% single-dose containers tients had central venous catheters, and 12 dextrose in water. Dextrose left to reside in received blood transfusions. Transmission the catheter lumen provides nutrients for for flush solutions. from transfusions and staff was ruled out, cells within biofilms; for this reason, the and molecular data suggested a patient-to- dextrose in water should be followed by a may be difficult to achieve when frequent use patient mode of transmission. In Septem- saline flush and heparin, if indicated. Also, of the catheter is required. ber 1998, the staff discontinued the use of heparin should be diluted in normal saline Ethanol and multiple antibiotics have multidose vials, monitored the HCV status instead of dextrose in water. also been used as catheter-locking solu- on admission, and admitted patients for The frequency of catheter flushing de- tions. At present these solutions are used high-dose chemotherapy to a private room. pends upon the clinical setting. For hospi- to treat catheter-related bloodstream infec- As of December 2001, no additional cases talized patients, flushing is most commonly tions rather than as a routine prophylactic had been identified. The authors point out performed after each intermittent infusion catheter-flushing or -locking solution. Some the lack of an established cause and effect or at 8- or 12-hour intervals if the catheter brands of polyurethane catheters have warn- but they do note that these preventive mea- is not being used routinely. For home-care ings about exposing the catheter to alcohol; sures proved successful in stopping disease patients, the frequency of infusion is less than therefore it is imperative to read the cathe- transmission. during hospitalization, and the catheter may ter’s instructions for use.18 Kokubo et al.24 have reported on 11 he- be flushed only once per day. For patients modialysis patients with nosocomial trans- receiving infusion therapy in an outpatient Flush solution containers mission of HCV. While they could not con- clinic, the catheter is flushed only on the days Current recommendations, guidelines, clusively establish the mode of transmission, when the patient visits the clinic to receive and national standards of practice strongly retrospective analysis suggested that it was therapy. A literature review15 of flushing pro- favor the use of single-dose containers for the sharing of multidose vials of heparinized tocols for tunneled central venous catheters flush solutions. The Infusion Nursing Stan- saline for catheter flushing. recommended 5 mL of 10 U/mL of heparin dards of Practice,10 Joint Commission for Another study of HCV, among pediatric once or twice per week when the patient was Accreditation of Healthcare Organizations,19 oncology patients, was conducted by Widell not receiving infusion but emphasized that and the Centers for Disease Control and Pre- et al.25 They identified 10 patients with acute more study is required to completely answer vention2 strongly endorse the use of single- HCV. All patients had implanted subcutane- this question. This recommendation corre- dose flush containers. The Institute for Safe ous ports with attached vascular catheters lates with the Infusion Nurses Society stan- Medication Practices reports frequently on and received many infusions. Due to corre- dard of practice that recommends using the the risk associated with multidose vials. lation of the same genotype and the timing lowest concentration of heparin so as not to Multidose vials of 0.9% sodium chloride of infusions among two patients, and a high negatively impact coagulation factors.10 contain benzyl alcohol as the preservative, number of used vials of saline found in the As shown in the studies discussed above, yet contamination is reported to be as high medication room, the authors concluded several alternative solutions are being inves- as 23% of vials.20 Benzyl alcohol is bacterio- that multidose vials were a primary mode tigated. These include EDTA and taurolidine static, not bacteriocidal; it has no effect on of transmission. citrate. Earlier research combined EDTA fungi and viruses, and gram-negative bacte- Another report, from Lagging et al.,26 with minocycline; however, intravenous mi- ria are the least sensitive to it. For adults, the about 3 patients with HCV following per- 4 nocycline is no longer available on the U.S. maximum dose of bacteriostatic 0.9% sodi- cutaneous cardiac catheterization, concluded market. Later studies using 40 mg EDTA um chloride is 30 mL in a 24-hour period.21 that the multidose vials of saline used for alone may prove it to be equally effective.16,17 When 10 mL of bacteriostatic normal saline catheter flushing were the most likely mode Clinical questions yet to be answered involve is used before and after each medication of transmission. the dosage and the length of time required dose, the maximum amount of preserved Krause et al.27 have described three pa- for the flush solution to be locked in the cath- saline is exceeded with only two medication tients who were hospitalized on the same eter lumen for maximum effectiveness. In- doses per day. Contamination of multidose nursing unit in a U.S. hospital and subse- vitro studies18 have reported exposure times saline vials is reported to be responsible for quently developed acute HCV. The HCV of 21 and 24 hours with EDTA; however, this nosocomial transmission of hepatitis B, hep- genotype plus clinical practices of using

www.infectioncontrolresource.org ResourInfectionce Control multidose saline vials supported the theory bags or bottles of intravenous solution as that the transmission came from contami- a common source of supply for multiple nated vials. Large-volume bags patients.34 Single-dose flush solutions are Plasmodium falciparum malaria was available in two forms: 10-mL single-dose transmitted to 20 pediatric patients in a Saudi of IV solution are often preservative-free vials of saline and prefilled Arabian hospital. Abulrahi et al.28 describe syringes. When the cost of labor and treat- how nurses admitted to using the same sy- used as the source of ment of nosocomial infection are included, ringe for flushing catheters of multiple pa- prefilled syringes are cost-effective. tients; however, the authors could not rule catheter-flushing fluid, out other means of transmission. Other IV system components In another report, Katzenstein et al.29 and this practice has A significant portion of the problems provided substantial genotyping and epide- with catheter patency could be related to the miological evidence to support nosocomial been implicated in design of syringes used for catheter flushing. transmission of HIV in an outpatient clinic. Most catheter manufacturers recommend The most likely mode of transmission was many nosocomial using a large (e.g., 5- or 10-mL) syringe for use of a multidose vial. catheter flushing to reduce the amount of Large-volume bags of IV solution are of- outbreaks of infection. pressure exerted against the catheter wall. ten used as the source of catheter-flushing Smaller syringes generate greater pressure fluid, and this practice has been implicated K pneumoniae bacteremia; 3 of them had on injection. Excessive force applied to the in many nosocomial outbreaks of infection. central venous catheters and 1 had a mid- syringe plunger with partial occlusion in For instance, 14 patients with central venous line catheter. One additional patient with a the catheter lumen from blood clots or drug catheters in an outpatient oncology clinic de- central venous catheter had a positive cath- precipitate can cause intraluminal pressure veloped Pseudomonas cepacia bacteremia, as eter-tip culture. As reported by Goetz et al.,32 great enough to produce catheter rupture. described by Pegues et al.30 Four additional saline for catheter flushing was taken from a In addition to syringe size, hand size and patients were asymptomatic but had P cepa- 100-mL bag, with a stopcock attached, that strength also add to the challenge, as these cia colonization of their central venous cath- was used until it was empty. Cultures from are difficult if not impossible to measure. eters. A 500-mL bag of 5% dextrose in water an empty bag and a partially used bag pro- These unknown factors cause the recom- used to prepare heparin flush solution pro- duced the same strain as that cultured from mendation for larger syringes for catheter duced a positive culture of P cepacia. Based all the patients. flushing. on the number of flushes prepared, it was Macedo de Oliveira et al.33 recently re- The other challenge with syringes is the estimated that this bag of fluid had been in ported how 4 patients newly diagnosed with design of the traditional syringe. When all use for 14 days. No other cultures of water, HCV began an investigation of practices fluid is flushed from the syringe, the tip on liquid soap, hand lotion, or povidone-iodine at their hematology-oncology clinic. The the plunger is compressed. To detach the were positive for this organism. practice of the clinic nurse was to use the syringe from the catheter hub, the force In another situation, 7 confirmed and 4 same syringe for obtaining blood samples on the plunger is released and the tip re- possible cases of polymicrobial gram-nega- from central venous catheters and to access bounds, pulling blood into the catheter tive bacteremia were reported from a sin- a 500-mL bag of saline for catheter flush- lumen. To avoid this problem, the nurse gle nursing unit in a community hospital. ing. This fluid bag was used for multiple could leave a small amount of fluid in the According to Chodoff et al.,31 all patients patients. Testing of 486 patients revealed 99 syringe. This technique requires learning had either a peripheral or a central venous with clinic-acquired HCV, with the same and practicing a new process, to which catheter flushed with saline taken from a genotype identified in 95 patients. This is busy nurses may not have time to devote bag of IV fluids. The practice was to add a one of the largest documented outbreaks attention. The other answer is to use only dispensing pin to either a 250-mL, 500-mL, of healthcare-acquired HCV. The patients’ a prefilled syringe designed to eliminate or 1000-mL bag of saline, and to discard the investigation resulted in closure of the clin- this plunger-rebound problem.18 Currently bag when it was empty or after 24 hours. ic and revocation of the oncologist’s and there are 2 brands of prefilled syringes de- Organisms isolated from patient blood cul- nurse’s licenses. The outbreak is currently tures included Enterobacter cloacae, Klebsi- the subject of litigation. ella pneumoniae, and Citrobacter freundii, These cases indicate that it is imperative and analysis of the bacteria with pulse-field to follow published standards and guidelines 5 gel electrophoresis revealed that many had for the use of single-dose flush containers. identical genetic patterns. The actual bag and Busy nurses with large workloads are under dispensing pin thought to be the culprits had pressure to meet patient needs. The task of been discarded, but the authors were able to drawing up the saline and heparinized sa- duplicate contamination of a similar system line into syringes adds to their burden and in the laboratory. opens the door for serious breaches of in- In the same nursing unit, 4 liver trans- fection prevention; nonetheless, as a 2003 MONOJECT PRE-FILL™ ADVANCED™ Syringe plant patients experienced 5 episodes of report from the CDC has stated, do not use (Tyco Healthcare Kendall)

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signed to eliminate syringe-induced blood valve.36-38 Research has not answered all the vent exposure to blood-contaminated reflux: BD POSIFLUSH™ Prefilled Syringes questions yet, as many hospitals are using fluid. (BD Medical) and MONOJECT PREFILL™ mechanical valves without any documented 2. Flush the fluid into the catheter, leav- ADVANCED ™ Syringe (Tyco Healthcare). increase in rates of CRBSI. ing a small amount in the syringe if us- Needleless injection systems were intro- There are several areas of concern. The ing one with a traditional design. Con- duced about 15 years ago as an attempt to topography of the connection surface of tinue to hold the plunger while closing reduce the number of needlestick injuries these devices makes it impossible to clean a clamp on the catheter or extension to healthcare workers. Currently, the Blood- them adequately before use, rendering it rela- set, and then disconnect the syringe. borne Pathogens Standard from OSHA35 tively easy for organisms to contaminate the mandates use of needleless devices. However, fluid pathway. A survey37 of nursing practice If you are using a positive-displacement through clinical use of these devices, other in one hospital with an increased CRBSI rate device, these techniques cannot be employed, issues have been revealed. The original design found that 31% of nurses did not disinfect as they will prevent fluid movement from the was a two-piece system: a blunt cannula at- the surface before connecting the syringe internal reservoir. If hospital policy requires tached to the male Luer tip of a syringe or IV or tubing. The connection surface of the that catheters be clamped, flush the catheter tubing, and a pre-cut slit in the injection cap needleless system must be cleaned before and detach the syringe. Allow a few extra sec- attached to the catheter hub. A one-piece me- each connection. For the SASH procedure, onds for the positive fluid displacement to chanical-valve injection cap was introduced this would mean cleaning four times with occur, and then close the catheter clamp. next, allowing for direct access with the male four alcohol pads. Although there are no Another flushing technique that has Luer tip of syringe or IV tubing. This original studies that have examined this issue, experts grown in use is the so-called pulsatile or design is often called negative displacement have recommended a 10- to 15-second alco- turbulent technique. This involves start-stop because of the potential for blood to move hol scrub of this surface before use. flushing in an attempt to create turbulence into the catheter lumen after flushing. Several catheter design factors have an inside the catheter lumen and to prevent The next design addressed the blood impact on flushing procedures. Three brands blood products from adhering to the inner reflux that could occur with the original of catheters have integral valves allowing for catheter wall. This technique is based on needleless devices. Mechanical valves with saline-only flushing. The GROSHONG™ the theory of fluid flow and has no in-vitro positive fluid displacement were introduced; valve from Bard Access Systems is built into or clinical studies to support its use. Ques- they hold a small amount of fluid in a reser- midline, PICC, nontunneled, and tunneled tions about it abound, including what is the voir. Upon syringe or tubing disconnection, catheters and implanted ports. The PASV™ amount of turbulence, if any, created by this this fluid is forced from the reservoir into valve from Boston Scientific is used in PICC technique; what are the differences between the catheter lumen to overcome the blood and tunneled catheters and implanted ports. nurses’ applications of this start-stop pro- reflux. There are many different brands of LifeValve™ from Rita Medical is available on cess; and what are the clinical outcomes seen these devices, with different amounts of implanted ports. with its use. Given the current knowledge of fluid held in the reservoir. The latest design A catheter’s length and internal diameter biofilm development inside catheter lumens, offers a mechanical valve with neutral fluid determine its internal volume, and this fac- including needleless injection systems, it is displacement, and there is no fluid move- tor determines the minimum volume for conceivable that this technique may enhance ment in either direction when the syringe flushing or locking catheter lumens. The the detachment of biofilm and increase the or tubing is disconnected. Several brands exact internal or priming volume for each rate of CRBSI, although there is no evidence have instructions for saline-only flushing, type and brand of catheter can be found in to support this theory either. and the manufacturers’ directions should the instructions for use that are packaged be followed. with each catheter. Conclusion Catheter lumen occlusion, with blood When all aspects are considered, catheter reflux into the lumen, is the major clini- Catheter-flushing technique flushing is much more than injecting some cal concern. As discussed, it occurs because The specific technique used to flush a fluid through the catheter lumen. Clinical of both the syringe design and the type of catheter depends upon the equipment be- outcomes depend upon the entire system needleless injection system being used. This ing used. Neutral-displacement needleless working together. The flushing technique reflux can easily be observed in a lab test; injection devices are not dependent on must match the needleless injection system however, there are very few clinical data on flushing technique. In the case of blunt can- design, yet many times the bedside nurse this problem, making it almost impossible nulas, positive-pressure flushing technique does not know what type of needleless device 6 to quantify the contribution of blood reflux is recommended to overcome the problem is being used. All brands look similar, and it to catheter lumen occlusion. of blood reflux. There are 2 approaches that is very hard to distinguish the types because The relationship of catheter-related can be used: they are not labeled by their fluid-displace- bloodstream infection to these needleless in- 1. As the last 0.5 to 1 mL of fluid is ment characteristics. Changing the type of jection devices has been the subject of grow- flushed inward, withdraw the blunt needleless system may not produce the de- ing concern over the past few years. Multiple cannula from the injection cap. This sired catheter patency if the syringe design is hospitals have found a dramatic rise in rates results in a spray of fluid on the ex- not considered. Above all, infection preven- of CRBSI after changing from a blunt-can- ternal cap and the hands of the nurse, tion techniques must be stressed, including nula/split-septum system to a mechanical mandating that gloves be used to pre- adequate cleaning of the needleless surface

www.infectioncontrolresource.org ResourInfectionce Control before each connection, choosing single-use 24. Kokubo S, Horii T, Yonekawa O, Ozawa N, Mukaide M. A phylogenetic-tree analysis elucidating nosocomial This continuing nursing education activity was flushing containers, and careful attention to transmission of hepatitis C virus in a haemodialysis unit. J Viral Hepat. 2002;9(6):450-4. approved by the Vermont State Nurses’ Association Inc. hand hygiene. Technology must be carefully 25. Widell A, Christensson B, Wiebe T, Schalen C, Hansson HB, (VSNA) an accredited approver by the American Nurses Allander T, et al. Epidemiologic and molecular investigation of Credentialing Center’s Commission on Accreditation. chosen to work with the appropriate tech- outbreaks of hepatitis C virus infection on a pediatric oncology niques, as neither can address the complete service. Ann Intern Med. 1999;130(2):130-4. 26. Lagging LM, Aneman C, Nenonen N, Brandberg A, Grip L, Upon completion of this program, the par- problem if used alone. Norkrans G, et al. Nosocomial transmission of HCV in a ticipant will be able to: References cardiology ward during the window phase of infection: an 1. Ryder M. Catheter-related infections: It’s all about biofilm. epidemiological and molecular investigation. Scand J Infect 1. Explain the development of biofilm in Topics Adv Pract Nurs eJournal [serial on the Internet]. 2005 Dis. 2002;34(8):580-2. vascular access catheters. [cited 2006 Sept 11];5(3). Available from: http://www. 27. Krause G, Trepka MJ, Whisenhunt RS, Katz D, Nainan O, medscape.com/viewarticle/508109. Wiersma ST, et al. Nosocomial transmission of hepatitis C 2. Identify the common protocols for 2. O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard virus associated with the use of multidose saline vials. Infect flushing vascular access catheters. SO, Maki DG, et al. Guidelines for the prevention of Control Hosp Epidemiol. 2003;24(2):122-7. intravascular catheter-related infections. Centers for Disease 28. Abulrahi HA, Bohlega EA, Fontaine RE, al-Seghayer SM, al- 3. Describe the components of catheter Control and Prevention. MMWR Recomm Rep. 2002;51(RR- Ruwais AA. Plasmodium falciparum malaria transmitted in flushing that increase the risk of 10):1-29. hospital through heparin locks. Lancet. 1997;349(9044):23-5. catheter-related bloodstream infection. 3. Donlan RM. Biofilm formation: a clinically relevant 29. Katzenstein TL, Jorgensen LB, Permin H, Hansen J, Nielsen C, microbiological process. Clin Infect Dis. 2001;33(8):1387-92. Machuca R, et al. Nosocomial HIV-transmission in an Epub 2001 Sep 20. outpatient clinic detected by epidemiological and phylogenetic 4. Correlate the appropriate catheter flushing technique to the needleless injection device 4. Shin JH, Kee SJ, Shin MG, Kim SH, Shin DH, Lee SK, et al. analyses. AIDS. 1999;13(13):1737-44. Biofilm production by isolates of Candida species recovered 30. Pegues DA, Carson LA, Anderson RL, Norgard MJ, Argent TA, being used. from nonneutropenic patients: comparison of bloodstream Jarvis WR, et al. Outbreak of Pseudomonas cepacia bacteremia Instructions isolates with isolates from other sources. J Clin Microbiol. in oncology patients. Clin Infect Dis. 1993;16(3):407-11. 2002;40(4):1244-8. 31. Chodoff A, Pettis AM, Schoonmaker D, Shelly MA. 5. Root JL, McIntyre OR, Jacobs NJ, Daghlian CP. Inhibitory Polymicrobial gram-negative bacteremia associated with 1. Read both articles. effect of disodium EDTA upon the growth of Staphylococcus saline solution flush used with a needleless intravenous epidermidis in vitro: relation to infection prophylaxis of system. Am J Infect Control. 1995;23(6):357-63. 2. Complete the post-test. (You may make copies of the answer form.) Hickman catheters. Antimicrob Agents Chemother. 32. Goetz AM, Rihs JD, Chow JW, Singh N, Muder RR. An outbreak 1988;32(11):1627-31. of infusion-related Klebsiella pneumoniae bacteremia in a liver 6. Raad I, Hachem R, Tcholakian RK, Sherertz R. Efficacy of transplantation unit. Clin Infect Dis. 1995;21(6):1501-3. 3. Complete the participant evaluation. minocycline and EDTA lock solution in preventing catheter- 33. Macedo de Oliveira A, White KL, Leschinsky DP, Beecham BD, related bacteremia, septic phlebitis, and endocarditis in 4. Mail or fax the complete answer and Vogt TM, Moolenaar RL, et al. An outbreak of hepatitis C virus evaluation forms to address on back rabbits. Antimicrob Agents Chemother. 2002;46(2):327-32. infections among outpatients at a hematology/oncology clinic. 7. Shah CB, Mittelman MW, Costerton JW, Parenteau S, Pelak M, Ann Intern Med. 2005;142(11):898-902. page. Arsenault R, et al. Antimicrobial activity of a novel catheter 34. Centers for Disease Control and Prevention (CDC). 5. To earn 1.5 contact hours of continuing lock solution. Antimicrob Agents Chemother. Transmission of hepatitis B and C viruses in outpatient 2002;46(6):1674-9. settings—New York, Oklahoma, and Nebraska, 2000-2002. education, you must achieve a score of 8. Raad I, Chatzinikolaou I, Chaiban G, Hanna H, Hachem R, MMWR Morb Mortal Wkly Rep. 2003;52(38):901-6. 70% or more. If you do not pass the test Dvorak T, et al. In vitro and ex vivo activities of minocycline 35. Hadaway LC. Safety legislation passed: H.R. 5178. J Vasc you may take it one more time. and EDTA against microorganisms embedded in biofilm on Access Devices. 2001;6(1):33-5. catheter surfaces. Antimicrob Agents Chemother. 6. Your results will be sent within four 2003;47(11):3580-5. 36. Jarvis W, Sheretz R, Perl T, Bradley K, Giannetta E. Increased weeks after the form is received. central venous catheter-associated bloodstream infection rates 9. Shanks RM, Donegan NP, Graber ML, Buckingham SE, Zegans temporarily associated with changing from a split-septum to a ME, Cheung AL, et al. Heparin stimulates Staphylococcus Luer-access mechanical valve needleless device: a nationwide 7. The fee has been waived through an aureus biofilm formation. Infect Immun. 2005;73(8):4596- outbreak? Presented at Association of Practitioners in educational grant from Covidien. 606. Infection Control; 2005; Baltimore, MD. 8. Answer forms must be postmarked by 10. Infusion Nurses Society. Infusion nursing standards of 37. Karchmer T, Cook E, Palavecino E, Ohl C, Sheretz R. Needleless practice. J Infus Nurs. 2006;29(1 Suppl):S1-92. valve ports may be associated with a high rate of catheter- July 21, 2013 11. Capdevila JA, Gavalda J, Fortea J, Lopez P, Martin MT, Gomis related bloodstream infection. Presented at 15th Annual X, et al. Lack of antimicrobial activity of sodium heparin for Scientific Meeting of The Society for Healthcare Epidemiology 9. Faculty Disclosure: No conflicts were disclosed. treating experimental catheter-related infection due to of America; April 16, 2005; Los Angeles, CA. Staphylococcus aureus using the antibiotic-lock technique. 38. Cosgrove S, Bradley K, McKee C, et al. Increase in catheter- 10. ANCC/VSNA do not endorse any commercial Clin Microbiol Infect. 2001;7(4):206-12. related bloodstream infections (CR-BSI) in pediatric intensive products. 12. Polaschegg HD, Shah C. Overspill of catheter locking solution: care units temporally associated with a change in the safety and efficacy aspects. ASAIO J. 2003;49(6):713-5. needleless intravenous port. Presented at Society for * VSNA and ANCC do not endorse any commercial products 13. Agharazii M, Plamondon I, Lebel M, Douville P, Desmeules S. Healthcare Epidemiology of America; 2005; Los Angeles, CA. Estimation of heparin leak into the systemic circulation after central venous catheter heparin lock. Nephrol Dial Transplant. 2005;20(6):1238-40. Epub 2005 Apr 26. Lynn C. Hadaway, MEd, RNC, CRNI The Infection Control Resource is a quarterly newsletter distrib- 14. Polaschegg HD. Loss of catheter locking solution caused by Ms. Hadaway is Executive Director of the Na- uted free of charge to healthcare professionals. The Infection fluid density. ASAIO J. 2005;51(3):230-5. tional Alliance for the Primary Prevention of Control Resource is published by Saxe Healthcare Communica- 15. Buswell L, Beyea SC. Flushing protocols for tunneled central tions and is funded through an educational grant from Covidien. venous catheters: an integrative review of the literature. Online Sharps Injury (NAPPSI) and is President of Lynn J Knowl Synth Nurs. 1998;5:3. Our objective is to explore practical, clinically relevant topics in Hadaway Associates, Inc., a consulting company the field of infection control. 16. Percival SL, Kite P, Eastwood K, Murga R, Carr J, Arduino MJ, providing services to the infusion segment of the Donlan RM. Tetrasodium EDTA as a novel central venous healthcare industry. She serves on the editorial The opinions expressed in Infection Control Resource are those catheter lock solution against biofilm. Infect Control Hosp of the authors only. Neither Saxe Healthcare Communications Epidemiol. 2005;26(6):515-9. review boards of the Journal of Infusion Nursing, nor Covidien make any warranty or representations about the 17. Kite P, Eastwood K, Sugden S, Percival SL. Use of in vivo- the Journal of the Association for Vascular Access, generated biofilms from hemodialysis catheters to test the accuracy or reliability of those opinions or their applicability efficacy of a novel antimicrobial catheter lock for biofilm and the textbook Nursing, published by Lippin- to a particular clinical situation. Review of these materials is eradication in vitro. J Clin Microbiol. 2004;42(7):3073-6. cott Williams & Wilkins. Ms. Hadaway is a past not a substitute for a practitioner’s independent research and 18. Hadaway L. Technology of flushing vascular access devices. J president of the National Association of Vascular medical opinion. Saxe Healthcare Communications and Covidien Infus Nurs. 2006;29(3):129-45. Access Networks, now known as the Association disclaim any responsibility or liability for such material. They 19. Joint Commission on Accreditation of Healthcare for Vascular Access. shall not be liable for any direct, special, indirect, incidental, or Organizations. Sentinel Event Alert: Infection control related consequential damages of any kind arising from the use of this sentinel events. 2003 January 22;28. Available from: http:// www.jointcommission.org/SentinelEvents/SentinelEventAl- ™ Trademarks of Tyco Healthcare Group LP or its affiliates publication or the materials contained therein. ert/sea_28.htm ™* BD POSIFLUSH is a trademark of Becton, Dickenson, & Co. This publication and the materials contained therein are the 20. Wilson J, Cobb D. Updating your multiple-dose vial policy: the property of Saxe Healthcare Communications, Covidien, or the 7 GROSHONG is a tradmark of BCR, Inc. background. Hosp Pharm. 1998;33:427-32. author, and are protected by copyright, trademark, and other 21. Gahart BL, Nazareno A. 2006 intravenous medications. 22nd PASV is a trademark of Catheter Innovations Inc. intellectual property laws. ed. St. Louis: Mosby Year-Book; 2006. 22. DeBaun B. Transmission of infection with multi-dose vials. LifeValve is a trademark of Rita Medical We welcome opinions and subscription requests from Infection Control Resource. 2005;3(3):1,5-7. Available from: our readers. Please direct your correspondence to: http://www.infectioncontrolresource.org/archive.html Saxe Healthcare Communications 23. Silini E, Locasciulli A, Santoleri L, Gargantini L, Pinzello G, For immedicate results you may take this P.O. Box 1282, Burlington, VT 05402 Montillo M, et al. Hepatitis C virus infection in a hematology test online at www.saxetesting.com Fax: (802) 872-7558 ward: evidence for nosocomial transmission and impact on he- [email protected] matologic disease outcome. Haematologica. 2002;87(11):1200- Upon sucessful completion of the post-test 8. online, your certificate can be printed © Copyright: Saxe Communications 2009 immediately.

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For quicker results, you may take this test online at www.saxetesting.com 1. Microorganisms attach to the catheter c. 20 to 25 ml of normal saline 11. Blood reflux into the catheter lumen is a. during the manufacturing process d. 5 to 10 ml of normal saline caused by b. during the packaging or shipping process a. syringe design and the type of needleless c. as it passes through the skin during insertion 7. The minimum volume for flushing all cath- injection systems d. as it resides in the bloodstream eters should be b. negative and positive displacement needle- 2. Biofilm develops because a. equal to the internal volume of the catheter less injection systems a. organisms produce adhesive material caus- and add-on devices c. positive-pressure flushing technique ing them to stick to the catheter b. twice the internal volume of the catheter d. positive and neutral displacement needle- b. slow flow rates of iv fluid allows for easy and add-on devices less injection systems contact with the catheter c. three times the internal volume of the cath- 12. The frequency for cleaning the connection c. rapid flushing techniques forces organisms eter and add-on devices surface on a needleless injection system against the catheter d. five times the internal volume of the cath- should be d. blood flow rates are not fast enough to flush eter and add-on devices a. once a week when it is changed them away. 8. Catheter flush solutions should be obtained b. once with each medication 3. Which of the following solutions supports from c. never as cleaning will not reduce the risk of the growth of biofilm? a. a prefilled syringe labeled for each patient infection a. heparin and dextrose b. a multiple-dose vial of normal saline stocked d. before each syringe or administration set is b. normal saline and dextrose in the medication room connected to the system c. heparin and normal saline c. a large bag of normal saline maintained in 13. Positive pressure flushing technique is re- d. edta and heparin the medication room quired when using 4. Bloodstream infection is caused by d. a multidose vial of diluted heparin supplied a. negative displacement needleless injection a. breaking of biofilm clusters which then float by the pharmacy system (blunt cannula) into the bloodstream 9. The maximum amount of bacteriostatic b. positive displacement needleless injection b. the volume of normal saline used to flush normal saline for an adult within a 24-hour system the catheter period is c. neutral displacement needleless injection c. the use of electronic flow control pumps a. 100 mL system d. the volume of heparin used to flush the b. 50 mL d. both positive and neutral systems catheter c. 30 mL 14. The pulsatile or turbulent flushing tech- 5. The purpose of using normal saline in the d. 10 mL nique flushing protocol is to 10. Flushing a central venous catheter with a 3- a. must be used on all catheters a. remove the biofilm in the catheter lumen mL syringe produces b. is not supported by any scientific evidence b. prevent the biofilm from forming inside the a. risk of catheter damage from high amounts c. will decrease the formation of biofilm catheter lumen of pressure in the catheter lumen d. will increase the formation of biofilm c. prevent contact between incompatible medi- b. increased risk of bloodstream infection by 15. Heparin may be eliminated when flushing cations disturbing the biofilm a. all brands of peripherally inserted central d. maintain patency of the catheter lumen c. risk of blood reflux into the catheter catheters (PICCs) 6. The most common volume for flushing a d. decreased risk of catheter damage because b. all types of central venous catheters central venous catheter is of the small size c. only when flushing an implanted port a. 1 to 3 ml of normal saline d. any catheter that contains an integral valve b. 25 to 30 ml of normal saline

Mark your answers with an X in Participant’s Evaluation the box next to the correct answer

What is the highest degree you have earned 1. Diploma 2. Associate’s 3. Bachelor’s A B C D A B C D (circle one) ? 4. Master’s 5. Doctorate 1 9 Indicate to what degree you met the objectives for this program: Using 1 = Strongly disagree to 6 = strongly agree rating scale, please circle the number that best reflects A B C D A B C D the extent of your agreement to each statement. 2 10

Strongly Disagree Strongly Agree 1. Explain the development of biofilm in A B C D A B C D vascular access catheters. 1 2 3 4 5 6 3 11

2. Identify the common protocols for flushing A B C D A B C D vascular access catheters. 1 2 3 4 5 6 4 12

3. Describe the components of catheter A B C D A B C D flushing that increase the risk of catheter- 1 2 3 4 5 6 5 13 related bloodstream infection. A B C D A B C D 4. Correlate the appropriate catheter-flushing 6 14 technique to the needleless injection 1 2 3 4 5 6 device being used. A B C D A B C D How long did it take you to complete this home-study program? 7 15 8 What other areas would you like to cover through home study? A B C D A B C D 8 16 Name & Credentials Position/Title Mail to: Saxe Communications Address PO Box 1282, City State Zip Burlington, VT 05402 Phone Fax or Fax: (802) 872-7558

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