Forum topic

I don't want to offend any ONS members, but I have found their standards to behind the venous access experts (INS and AVA).

Gwen Irwin

Austin, Texas

No offense taken, Gwen.  ONS has a publication entitled "Access Device Guidelines:  Recommendations for Nursing Practice and Education" and now has an online course utilizing this publication.  I took this when it first came out a couple of years ago, so I am referencing the second edition (2004) of the above publication.  I am quoting from pg 5, under the heading of common maintenance procedures:

"Maintain strict aseptic technique for all procedures . . . "  They go on to talk about clean technique in tunneled caths after healing.  Does anyone want to take exception that "strict aseptic technique" is not sterile?

The ONS Chemo/Bio guidelines don't even adress the access procedure, other than choosing the correct needle size and obtaining blood return.  Core curriculum does not address it either. 

As an ONS member who was the central line "troubleshooter" at my previous workplace, I learned much from the IV-therapy.net group of infusion nurses and appreciated having you all as a resource for extra difficult problems.  As you can see, I'm still lurking around, learning what I can.  Infusion therapy nursing practice is so integral to what we do in oncology.  I am one individual serving as a bridge.

I should add a couple of other things.  The oncology population has some uniquenesses and I'm speaking primarily of neutropenia.  With neutropenic patients, I think the use of sterile technique becomes even more important when we're dealing with dressings. 

Gwen, I should also add I am an AVA member as they deal with access devices which is so germaine to oncology nursing practice.  We, in oncology, can utilize the knowledge/research of our colleagues in vascular access and infusion therapy and combine it with our knowledge of chemotherapy.  Hopefully, better patient outcomes will be the result.

I would agree that sterile technique is required when accessing an implanted port for all the reasons already well stated. I do know that there is a movement in physician's offices to cut cost by using only clean technique, however I do not think this is going to produce the best outcome for the patient. Catheter related bloodstream infection can be eliminated with proper technique. A rate of zero is achievable, but not if we go backwards. Also I am not aware of any clinical studies that have shown clean technique to produce no BSI, so I would only want to do sterile technique for this access. 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

I'm about to debate this "sterile vs clean" port accessing. In my mind it's a no brainer and quoted verse and page of the INS standards. I'm actually getting resistance on this issue, in this day and age of bundles and non-reimbursement. I know the CDC is getteing ready to issue new guidelines but where is the ONS on this issue?

Reading here http://onsopcontent.ons.org/Publications/SIGNewsletters/chemo/chemo20.2.html

Accessing Implanted Ports: Sterile or Clean Technique?

"The ONS Access Device Guidelines (2004), which are now five years old and do not include the use of chlorhexidine gluconate (CHG), designate it as a clean procedure." (written 4/09)

This contradicts Donna's statement below, anybody know for sure where the ONS stands?

I still say that the ONS standards do not explicitly say to use a mask during port access.  Am I wrong?  The last version of the ONS standards did not specify this.  This is my greatest concern.  Locally, we have oncology nurses in doctors' offices that do not follow the INS standards.  They say they are following the ONS standards.

Our patients are telling us the difference between the oncology sites and our techniques for accessing ports.  We continue to recognize the difference in practice.

Please update me on the ONS standards and give me a reference to show them, too.

Gwen Irwin

Austin, Texas

So, I still go back to the 2/3/09 comment that ONS standards are behind the INS recommendations, right?

If I have a port or my family member does, I want the INS standards followed. Which includes using sterile technique.

Gwen Irwin

Austin, Texas

Of the two studies I'm aware of that used clean technique, BOTH were done in the OUTPT setting.  I don't think it's a good idea to generalize those studies (needle in & out within one day) to an inpt population where needles stay in for up to a week.

I received the following in Emailbox today and was shocked by the contents (details of aseptic Port access) and the source (ONS)

http://info.navilystmedical.com/Blog/bid/25372/Studying-Port-Access-and-...

If it's my port your sticking....IT'S ALWAY STERILE regardless of in or out-patient!!!! (from a vascular access specialist in a cancer institute)

Seth Eisenberg, ONS chemotherapy SIG newsletter editor published a recent summary of port access: clean vs. sterile in the April, 2009 newsletter.  It can be accessed about half way down on this website: http://onsopcontent.ons.org/Publications/SIGNewsletters/chemo/chemo20.2.html

Although he states there have been no studies comparing the two techniques, this is not true.  The first reference I have is:

Long, C. and Ovaska, M.  (1992).  Comparative study of nursing access protocols for venous access ports.  Cancer Nursing 15(1): 18-21.  Very small sample size of 26 pts divided into two groups with no difference in the access procedure except for the use of sterile (Group I) vs. clean gloves (Group II).  There were totals of 69 (I) and 102 (II) accesses.  Pts were not crossed over between the two groups.  The presence of infection was determined by elevated WBC, febrile episode (100.4) or drainage, pain, erythema, swelling or warmth at the port site.  Results were no documented infection in either group:  no febrile episodes and no site problems.  The only stat cited for WBC is a range:  2.2-8.9 (I) v. 2.0-13.9 (II).  "The results of this study support a recommendation that nursing protocols be changed in this chemotherapy outpt department . . . " to the clean technique protocol.  That was the conclusion.

The Long and Ovaska study also cites a study by Lisa Schulmeister (1987).  A comparison of skin preparation procedures for accessing implanted ports. NITA 10:45-7.  I have not seen this study, but the lit review in the Long study states 40 pts were studied over a 1 yr period and compared clean v sterile procedure.  Ports included were both in outpts and inpts.  No febrile episodes or septicemia occured in either group.  "This study found that the clean, nongloved technique was more time efficient and cost effective.  Further replication was recommended."  I might email Lisa and see if she will send me this publication.

I believe there was a study published this last year in one of the oncology nursing journals, but I'm having trouble laying my hands on it.  If memory serves me correctly, Dawn Camp-Sorrel was the author.  I'll look and post again when I find it. 

It was Dawn Camp-Sorrel in the Clinical Journal of Oncology Nursing, Oct 2009,  13(5): 587-590.  The title is  "Accessing and Deacessing Ports:  Where is the Evidence?"  I am a bit puzzled by the conclusions the author draws. 

The author uses retrospective chart review of a 1 yr period to evaluate the infection rate in oncology outpts with ports seen in their rural hem/onc practice who had received at least two cycles of chemo.  All of these pts' ports were accessed using an "aseptic" procedure involving nonsterile gloves, chlorhexidine, ethyl chloride spray, then access and dressing (in that order).  Of 62 evaluable pts, 6 became infected (3 systemically, 2 exit sites, 1 port pocket).  The author concludes that 5 of these infections are NOT attributable to the nonsterile gloved procedure because " . . . five were hospitalized before the diagnosis of port infection."  There is no data about how long the patients were hospitalized prior to receiving a port infection/bacteremia dx.  One pt was admitted with febrile neutropenia and the blood culture showed gram+ cocci.  In my experience, blood cultures are drawn immediately on pts being admitted for febrile neutropenia (or in the ER), but the article doesn't say if there was any lag between admission and cultures.

The second puzzling conclusion is "Because no significant difference in infections was observed between sterile and nonsterile gloved procedures in the current study, infection seemed to be related more to the type of skin preparation and handwashing than the type of glove used; the finding is in agreement with O'Grady et al's (2002) data."  (This is the CDC publication on prevention of intravascular catheter-related infections.)  There was no indication in the study that more than one procedure was used for accessing the ports, so  I'm not sure what the author is referring to.

Anyway, this one conclusion seems to indicate it was a comparative study, but I don't see it in the data.

Thank you  Donna for staying vigilant on this topic!