We are well aware of the IV tubing change recommendations by the new CDC guidelines. We are also aware this issue has been discussed at many IV listserves recently.
But we would still like to know the standard of practice of TPN tubing change frequency in other hospitals. Please respond to the following questions:
1. How often do you change TPN tubing if it is y'ed with intralipid close to the catheter hub?
2. How often do you change TPN tubing which is directly connected to the catheter hub or y'ed with other stable solutions (not intralipid)?
Thank you in advance for your answers.
Toshi Holland
Children's Hospital & Research Center Oakland
The standards committe had lots of discussion about your #1 question!! Reference #7 on page S56 of the standards is all we could find in 2009-10 when we were doing lit searches. I am not sure if there has been anything else published on this issue or not. I am also eager to hear what others are doing about that short segment of extension set that is exposed to IVFE. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I would also like to know what others are doing in regards to this practice change. In our NICU and PICU we often have TPN without lipids running which per CDC/INS would mean a 96 hour change, which many of my colleagues feel is "icky" and want to keep the 24 hour change we have been practices. I do understand that the purpose of the 96 hours is to decrease breaking into the IV site. My Pediatric Phramacist pointed out that we change the TPN bag daily and that often addtives are changed daily by the provider. In the NICU and PICU the TPN is often going at a low rate so it would take a while for the tubing to be cleared of the "old TPN" formula, so is that is a concern. If lipids are ordered separately they are often y-into the TPN, so there is mixing of the TPN and lipds in the y-set, so I would also like to know the answer to the question you posed in #1. I certainly want to adhered to evidence-base and best practices but there are some valid concerns posed by NICU and PICU colleagues that I feel need to be addressed before we consider moving to 96 hours.
Hope others with answers will comment! I posed this on my advance practice AACN listserv-I will let you know if I get any info from the group!
-Patti Laliberte, RN, MSN
Pediatric Clinical Nurse Specilaist
New Hampshire Hospital for Children/Elliot Hospital
Manchester, NH
Toshi:
I just spoke to a NICU Nurse Educator I know at Chilldren's Hospital of Atlanta. If the have TPN and Lipids y-sited together into the same line then they change the entire set-up down to the hub every 24 hours. When they were not doing this they noted a higher CLASBI rate and thought it could have been the lipids left in the y-connector that were causing the problem. Their hospital is an IHI mentor site for Central Line related questions so trust their judgement on this issue.
Our NICU plans to keep with a q 24 hr change as we generally have TPN and lipids y-connected into the same line. Hope this helps!
-Patti Laliberte, RN, MSN
Pediatric Clinical Nurse Specialist
NH Hospital for Children
Manchester, NH
In our Hospital we currently do the following:
1. Lipid lines are changed every 24 hours - irrespective of where they are sited - this includes the 3-in-1 solutions
2. Clear fluid PN lines are changed routinely if the PN is on continuous infusion - every Monday, Wednesday & Friday - although CDC guidelines recommend 96 hours - the practical application in the clinical setting is far more challenging - anecdotal evidence told us that lines aren't always changed when they are meant to be - the risk was too high to allow therefore we chose to use these days of the week to ensure there was some regularity and increased staffing in areas where patients are big users of PN - e.g. Oncology. So what we did was take a risk management approach to our policy/guidelines.
If the PN is started on any of the days outside of Mon/Wed/Fri then the line change occurs at the nearest day to bring them into the routine cycle - this has been in place in our Hospital since we undertook the systematic review back in 2002ish.
We too change the PN solution every 24 hours.
Our cochrane review on timing of line changes certainly allowed us to change our practice but also highlighted to the clinicians across the Hospital that the more you change and "fiddle" with the lines the greater the risk of infection - it is hard to argue with the evidence.
cheers.............. Karen
Karen Rankin
Clinical Nurse Consultant
the Children's Hospital at Westmead - Australia
Karen, it would appear to me that your change on Mon-Wed-Fri increases hub and tubing manipulation, thus increasing the risk of contamination, colonization (aka biofilm formation) and infection. I am curious as to why you did not choose Monday and Thursday instead which would seem to serve both staff problems and manipulation problems.
I think the original message was actually addressing an issue that has been studied very little with IV sets and PN/lipids. When the lipids are piggybacked into the PN set, or when the lipids are infused through one lumen of a multiple lumen extension set, the lipids are in contact with a small set of the extension set that may not be changed on a daily basis. The question is then, if lipids have been exposed to any portion or segment of the entire system, does this mean that the entire system should be changed on a daily basis? If so, do we reattach the PN set to the new extension or change all sets every 24 hours. There is only one reference examining this issue, listed in INS SOP, page S56, reference #7. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861