Forum topic

Gina,

I think this organization is confusing aseptic/sterile with clean technique.  Clean technique is what it seems that they are doing, in some instances you sited, however, in others it doesn't appear that they are even using that!

Being ignorant of current and appropriate standards of care, is NO excuse.  This entire organization is setting themselves up for bad patient outcomes, not to mention lawsuits from inappropriate care.  You really don't think that you are wrong in this I'm sure, it's just that you are so frustrated by their actions... I would be too, and I would be declaring the same sentiments regarding my return there.

Both INS and ONS have standards which delineate the appropriate access of an implanted port and it should be sterile/aseptic.  However, there are those nurses who believe that aseptic technique only means clean technique.  But, I agree with you and this facility needs education.

Do you have a INS standards book? It is available online to order at www.ins1.org .   This and ONS standards will be your best bet for proof, substantiating documents.

Gina,

Your concerns are valid.

I recently rewrote our entire implantable port policy using current standards. I have been doing the “circuit” on skills days at the different departments.

I find that nurses sometimes think that “sterile” means the operating room. Did you scrub in? Are you in a sterile environment? Are you completely  gowned? People have questioned me on “sterile” for ports. I think, once again the semantics of aseptic and sterile comes up…but clean is totally different.

The thing with ports is that we are using sterile supplies and accessing the port aseptically  (so NO, it is NOT clean technique).  I find that description is best understood.

It is crucial that they understand about sterility. I am telling you, they will drop non-sterile prefilled saline syringes and etc. onto all kinds of sterile fields if they do not get this. They question me constantly. “Since when did we have to do this for ports?”

You can easily provide INS and ONS Standards. Or, explain/remind that is it a central line….it has a tip which hopefully terminates in central circulation. That 3 to 6% of ports get infected. That our patients can get a BSI from poor technique with ports.

Ask them if it was a subclavian  or PICC, would they scrub the hub? Would they do a sterile dressing change? Hopefully, they said yes….and then explain why there is not any reason not to do it with this type of central access device.

You’re being a great advocate for your husband, which may end up changing some practice and then protecting even more patients.  You may not feel that now, but someone will think about what you said, and change may be adopted eventually.

Take care,

 Kathleen

Gina, first I am sorry to hear about your husband's diagnosis, but am glad he has you to help him. You are absolutely correct about the lack of sterile technique in many of these ambulatory infusion clinics. I know of infusion nurses (RNs) that have left jobs in some of those clinics due to this lack of adherence to national standards and clean technique for accessing am implanted port was their issue. This issue did receive attention fromt the INS standards committee and we searched hard to find published evidence to support the safety (or any outcomes) with using only clean technique for accessing implanted ports. We could not find any studies in support of this technique, thus we have included what is actually in the 2011 document. Also show these nurses Standard #1 which states that this document applies to all infusion therapy performed in all settings by all nurses. So it will be the first document used to measure their practice if there is ever a lawsuit brought against them. I hate to use this or any other document to avoid the threat of a lawsuit but in some cases they will not get the message any other way. If they refuse to follow the INS standards and ONS guidelines, then your only option is to go to another clinic for your infusions, but hope that you can get them to change their practice. That will mean great benefits for all their patients. Many times, these decisions are motivated by money and the lack of reimbursement for the appropriate supplies.

One other new initiative is the Association for Safet Aseptic Practices (www.asap.org) from the UK. CDC, APIC, INS, and AVA have all begun to listen to this group because they are making a lot of sense. There has not been a standardized way to apply the word "aseptic". Did it mean sterile technique or clean? In the 2011 INS SOP, there is this definition for 'aseptic" which is the same as what is used by APIC - Aseptic Technique - a set of specific practices and procedures performed under carefully controlled conditions in order to minimize contamination by pathogens.

For any and all vascular procedures, we must eliminate this idea of "clean" technique and use aseptic technique which would require sterile gloves, and thorough skin prep and an occlusive dressing while the port is accessed. Lynn

The correct link for the Association for Safe Aseptic Practice is listed below

http://www.antt.org.uk/ANTT_Site/home.html

This subject is so close to my heart [literally] and if I could have you as my carer I would.. welcome to the world out there.  and I am sorry you had to find out. I have that same attitdue to deal with and the only way is to refuse any care by these so called nurses. AS a patient its horrifying, as a fellow nurse is totally disgusting that nurses think they have the right to do the lowest form of care out in the community, and think they are clever about it.

 I will admit to do a modified ANTT when I  de access my port, but as an old operating room nurse, I know what I am touching and what not . I also know that putting clean gloves on does not mean that they are magic and what they touch cannot pass bugs or contaminate.

what is horrifying is to go to Utube and see  tutorials on ports being accessed... yup along comes nurse with  gear in a kidney dish [non sterile] hair flopping around the place, no gloves no hand washing..  pulls back patients clothing does that magical swipe with what ever. and stabs the now very unsterile huber needle in. grabs a nonsterile swab and slaps some tape over, the roll of course coming out of her pocket.. From both the UK and USA we have very serious tutors showing how they can contaminate a  site at least 5x in the 2min of education. 

 I am glad to say I am not popular as a nurse, when I see it happening where I work, and I am very proud to be an uncooperative patient, when I meet such professional nurses.[sic] There is a reason we are  un cooperative. ......................we want to live... as you want your husband to get his treatment without medical misadventure. 

 I am glad that I do  get to read the topics on here, and learn the right way, so that other people in my support group then also have data to show to their 'health provider'. you have helped me to go over 12 yrs with CVADs and other things, without an infection.

Gina first sorry to hear about youir husband

You have however encountered my disagreement with standard of care

ONS gudielines suggest use of non sterile gloves to access a port.  This is so insane as the minute one uses their non sterile gloves to stabalize the port staph is all over the prepped skin.  The problem is no physician office is responsible for infections or cost of treatment of an infection like a hospital.  Therefore no accountability.  Port infections were noted on the rise recently.  ONS RN's have told me that they do not have to stabalize the port to place the huber. RIGHt.  So they get a pass on sterile technique and the costs associated with infection from clean tehnique as they have no one to report infections to. 

INS Standards suggest sterile technique.  It is obvious this committee thought thru the process step and step and realized that sterile gloves are needed to stabalize the port to place a huber and to check for blood return you need sterile syringes with saline.  Kudo's to INS for visualizing the procedure

what I have found is hospitals and major oncology centers are using sterile technique but MD offices are going iwth tape no dressings and non serile access.

ONS gives a pass on technique so they unfortunatley are practicing to the guide given but is the guide right?

Kathy

Gina, never shy away from being there for my family members.  I think I got the moniker of "vigilante" in one hospital . . . so you go girl!

Three studies are cited below.

I have posted this first study before about clean vs. sterile technique . . . note it was done in an outpt setting so not generalizable to inpt settings where needles are left in place for up to a week.

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 indicates 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 occurred in either group.  "This study found that the clean, nongloved technique was more time efficient and cost effective.  Further replication was recommended."

A third study was published more recently, but I came away with some questions about the conclusions drawn.

The author 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?"   

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 or the interval from hospital discharge to eventual 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 methods that more than one procedure was used for accessing the ports (see paragraph above--nonsterile gloves), 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.

I would like first to thank you for posting the so called evidence cited for clean technique

Not one prospective, randomized, or blinded study

I believe Sorrell works for a MD office and clean technique is a major cost savings to MD office.  MD offices are also not penalized for infections nor do they have to report infections. 

INS Standards have it right as I see no way one can access a port without putting their dirty hands with their dirty clean gloves from a community box all over the patients skin/chest to stabalize the port while they secure it to place the huber.   I was told by a high level ONS RN that they are so good they do not have to palpate the port or secure it in place to access so therefore they could use clean technique.  Who is kidding who!

Also how do they check blood return without a sterile syringe barrell.  so their dirty gloves are all over the syringe barrell before a dressing is even applies. 

Can someone say Staph

Kathy

The list has disscussed this issue in the past http://www.iv-therapy.net/node/2377 It was quite a challenge for me to change the policy in my institution. The "discussion" with PA's ONS RN's and nursing suits (upper managers) had got me so heated that I basically thew up my hands and said, " if the hospital does not want to base policy off of national standards so be it. As an RN, I personally will use best practice models and national standards in my practice and will document it as such and walked out of the meeting. BTW they did change the policy but not the practice of some (many?) There is still not enough education and monitoring of compliance IMO.  Very sorry you have this extra burden of poor nursing practice to deal with Gina. If that were the only problem you could solve it with literature. What I find the most difficult and frustrating to deal with is the attitude and ostracizing that comes from some people I reluctantly call colleagues. I hope and will pray you find the right place to take your husband, no one will know that better than you.

There is nothing harder that doing what you know to be right against the inertia of a system where you are ostrasized for not just going along. Thomas Jefferson said " One man with courage is a majority." God Bless You for doing what is right. Your family is the best argument for consumer portability in health insurance. Keep looking until you find someone who will do what is right.

http://covan.info/wp-content/uploads/29camp-Sorrell.pdf  

STATE OF THE SCIENCE OF ONCOLOGY VASCULAR ACCESS DEVICES

DAWN CAMP-SORRELL

"MAINTENANCE CARE: WHERE IS THE EVIDENCE?

Current maintenance care procedures used in clinical practice are often not based on evidence but rather on manufacturer recommendations.12 These recommendations are usually based on trials used to have the device or product approved by the US Food and Drug Administration (FDA), therefore are not randomized controlled studies. Although few areas of VAD care have beenestablished and well-recognized as evidence-based (see Table 2), multiple controversies still exist in VAD care (see Table 3). Regardless of the method used, it is imperative that a standard procedure be adopted by the institution and followed by all personnel who care for VADs.5,12-14 Consistent VAD maintenance and care assists in decreasing the incidence of the two most common complications, infection and occlusion. The purpose of maintenance and care is to extend the life of a VAD and to prevent  complications. 2,9 Dressings serve to protect the VAD exit or insertion site from potential organisms located on caregivers’ hands or organisms located on the patient’s skin.7 Basic steps in dressing changes include washing hands, removing the old dressing, inspecting the site, cleansing the site, and applying  a new dressing. Recommendations, based on research, for the type of dressing (gauze vs. transparent) and how often to change do not exist. The majority of research in this area is more than 10 years old, with small sample sizes, and with the use of older transparent dressing designs.8 Another important way to prevent infections of VAD is strict hand washing before and after all care.14,15 To date, the question of using sterile versus nonsterile gloves has not been adequately researched. Full sterile equipment for VAD insertion has been found to be vital in preventing infections. However, in routine maintenance care, sterile drapes, mask, gown, and gloves have not been studied as being beneficial in decreasing the incidence of infection, including the cost implications. Recent changes in hospital reimbursement from the Centers for Medicare and Medicaid Services (http://www.cma.hhs.gov) have prompted inpatient facilities to reevaluate the methods used to prevent infections Although changes have been made within institutions, no recommendations have been given on what type of changes should be made in VAD care that will decrease the incidence of hospital-acquired VAD infection."