Accessing connectors

Section Recommendation statement Grading
20. Catheter hubs (including needleless injection sites and blood sampling ports) must be vigorously cleaned with antiseptic swabs (containing no less than 0.5% chlorhexidine with alcohol, 70% alcohol, or if allergic 10% povidone-iodine) before and after use to ensure removal of microorganisms and particulate matter. The solution must be allowed to dry naturally prior to accessing the device i.e. scrub the hub (1,2). Grade A
21. When an unused lumen is accessed to administer a medication or commence an infusion, a small volume of blood should be gently aspirated and discarded and the lumen flushed with 10mL 0.9% saline prior to medication administration or fluid commencement (3). Consensus
The evidence review for these recommendations was current to December 2015. Clinicians are advised to check the literature as research may have been published that change these recommendations.

Needleless hubs on intra vascular devices and administrations sets are now common across healthcare facilities. While these significantly reduce the risk of accidental needle injury for healthcare workers there has been a rise in catheter-associated blood stream infections and central line associated bloodstream infections (4-6)(CLABSI). Implementation of the Central line bundle has seen sustained decrease in CLABSI across Australia (1); there are however late CLABSI that are likely due to substandard maintenance practices with associated contamination of the hub leading to intra luminal biofilm development (7).

Risk factors for infections (7) include:

  • poor adherence to infection prevention practices including hand hygiene and aseptic technique (eg less than 40% of hubs may be decontaminated before accessing)
  • design of needleless hub
  • inconsistent healthcare staff education and training.

When deciding on the antiseptic solution considerations include:

  1. needleless hub design
  2. physical action of disinfection (time and action)
  3. effectiveness of antiseptic in eliminating bacteria for a sustained period.

There is conflicting evidence regarding how long a catheter hub should be cleaned for however a minimum between 5(2) and 15(1) seconds has been recommended in international guidelines.

Practice point - Accessing CVAD

  • Perform hand hygiene as per the five moments (moment two).
  • Put on clean gloves prior to accessing the device.Perform a “hub scrub” using an alcoholic chlorhexidine wipe and friction in a twisting motion on the hub as if you were ‘juicing fruit’.
  • Infuse medication or draw blood and label as per policy. Discard gloves and perform hand hygiene (moment three).

Aspirating a small volume of blood and flushing unused lumen ensure that the CVAD is assessed for patency and that no residual product within the lumen of the CVAD is inadvertently administered to the patient. The group felt this was a good patient safety measure. Further, it enables staff to assess that the lumen is in the vessel if blood is able to be aspirated. In some devices (such as catheters inserted to provide renal replacement therapy) it is an essential component of assessment to promote appropriate therapy. However, aspirating and discarding blood through mechanical needleless valves may have the potential to increase risk of infection and luminal occlusion, particularly in smaller bore devices. The practice review indicated that 5mL was the most common volume aspirated by those responders that indicated aspirating formed part of routine practice (n=24/50 aspirate 5mL total responders n=120). The GDN felt this volume was unnecessarily large and the volume of aspirated blood should not exceed the internal lumen volume in order to reduce the risk of induced anaemia. For many CVADs this volume would not be greater than 2mL. In some cases, blood may not be able to be aspirated, which does not exclude use of the device.

Grading of recommendations

Grade of recommendation Description
A Body of evidence can be trusted to guide evidence
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation/s but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Consensus Consensus was set as a median of ≥ 7

Grades A–D are based on NHMRC grades (8)

References

  1. Loveday H, Wilson J, Pratt R, Golsorkhi M, Tingle A, Bak A, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection. 2014;86:S1-S70.
  2. Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O’Grady NP, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology. 2014;35(S2):S89-S107.
  3. Society IN. Infusion Nursing standards of Practice. Journal of Infusion Nursing. 2011;34(1S):S1-S109.
  4. Btaiche IF, Kovacevich DS, Khalidi N, Papke LF. The effects of needleless connectors on catheter-related bloodstream infections. American journal of infection control. 2011;39(4):277-83.
  5. Hadaway L. Needleless connectors: improving practice, reducing risks. Journal of the Association for Vascular Access. 2011;16(1):20-33.
  6. Jarvis WR, Murphy C, Hall KK, Fogle PJ, Karchmer TB, Harrington G, et al. Health care-associated bloodstream infections associated with negative-or positive-pressure or displacement mechanical valve needleless connectors. Clinical Infectious Diseases. 2009;49(12):1821-7.
  7. Moureau NL, Flynn J. Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review. Nursing research and practice. 2015;2015.
  8. Hillier S, Grimmer-Somers K, Merlin T, Middleton P, Salisbury J, Tooher R, et al. FORM: an Australian method for formulating and grading recommendations in evidence-based clinical guidelines. BMC Medical Research Methodology. 2011;11:23. PubMed PMID: 21356039.

Disclaimer

The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.