On a recent state survey, I received a negative comment because I had not secured the waist tie on my sterile gown. The velcro neck tabs hold the gown securely so it has never fallen down and, generally, we are wedged into a space so tiny we couldn't turn around if we wanted to (not very ideal but the back of a sterile gown is not technically considered sterile anyway, right?). We are a solo PICC department with only one nurse on at a time so no buddy to tie it. The double rooms are so small that getting anyone close enough to tie the gown is all but impossible without risking contaminating the rest of the sterile field providing we could get someone in the room in a timely fashion.
My question: Is our failure to tie the waist tie on the sterile gown really a practice that could negatively effect patient safety? If the answer is a definite yes, could you suggest of a solution that would make sense given the circumstances?
Tying all closures on a sterile gown is necessary as those ties can flap into the sterile field. As you have already mentioned, the back of the gown is not considered sterile so neither would those ties. Frankly I don't know how you have room enough to put on a sterile gown without contamination in the very small space you described. There are methods and specific features on some gowns that allow it do be done exclusively by the wearer. If you do a search on Google, you will find numerous video clips. There are gowns with the ties located at different positions and lengths to allow the wearer to do it alone. You may need to have another gown with these ties made available to you or get help with the entire procedure. The extra person is now recommended for many reasons during insertion of all CVADs, including PICCs. The checklist should be completed for each procedure and NO ONE can complete this checklist for their procedure after they have finished. It requires a trained person watching the steps of the procedure to ensure that all aspects have been performed correctly. This information about the checklist being completed by someone other than the inserter is included in the 2014 SHEA Compendium chapter on CLABSI. 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
In addition to Lynn's recommendation about the Checklist compliance, here are other references on the subject.
1. Infusion nursing standards of practice. Infusion Nurse Society. 2011, Journal of Infusion Nursing, pp. S1-S110.
2. Association of periOperative Registered Nurses. Perioperative Standards and Recommended Practices. ISBN-10: 188846075X : AORN, Inc. , 2014.
3. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. American Society of Anesthesiologists. 2012, Anesthesiology, pp. 539-73.
4. Center for Disease Control. Checklist for Prevention of Central Line Associated Blood Stream Infections. . CDC. [Online] December 17, 2014. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf..
5. O'Grady NP, Alexander M, Burns LA, et al and Committee, and the Healthcare Infection Control Practices Advisory. Guidelines for the Prevention of Intravascular Catheter-Related Infections. Center for Disease Control and Prevention. [Online] 2011. [Cited: October 19, 2014.] http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf.
6. Staiger TO, Peterson GN, et al. A Collaborative, System-Level Approach to Eliminating Healthcare-Associated MRSA, Central-Line_Associated Bloodstream Infusion, Ventilator-Associated Pneumonia, and Respiratory Virus Infections. 2012, Journal for Healthcare Quality, pp. 39-47.
7. Lesmaster CH, Hoffart N, Chafe T, Benzer T, Schuur JD. Implementing the central venous catheter infection prevention bundle in the emergency department: experiences among early adopters. 2014, Ann Emerg Med, pp. 340-350.
8. Emergency Medical Treatment and Active Labor Act (EMTALA) 1986. Frequently asked questions. http://www.emtala.com/faq.htm. Accessed on Januray 13, 2015.
9. Agency for Healthcare Research and Quality (AHRQ). Tools for Reducing Central Line-Associated Blood Stream Infections: Appendix 9 :Back to Basics. http://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools.... Accessed January 22, 2015
10. Lillis K. Infusion-Related Infection Prevention: Ignoring Little Details Can Lead to Big Problems. Infection Control Today. 2013 http://www.infectioncontroltoday.com/articles/2013/05/infusionrelated-in.... Accessed January 22, 2015
11. The Joint Commission. National Patient Safety Goals. 2015 http://www.jointcommission.org/assets/1/6/2015_HAP_NPSG_ER.pdf. Accessed January 22, 2015
12. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine 2006;355(26):2726. http://www.nejm.org/doi/pdf/10.1056/NEJMoa061115. Accessed January 22, 2015
13. http://www.jointcommission.org/assets/1/6/CLABSI_Toolkit_Tool_3-17_Centr...
Literature is very clear, if we are going to follow CDC and professional organization recommendations, a second knowledgeable person must be present during the procedure. Not only to assist in tying the gown but also to complete the checklist and be "empowered" to stop the procedure and correct any break in sterile technique.
R. Terry Jones, RN, CRNI, VA-BC
Memorial Hermann Northeast Hospital
Humble, Texas
It sounds to me in the circumstances, you're at greater risk for contamination trying to tie the gown. In so many situations there simply is not going to be a second person. If I were in your situation I would ask the infection control nurse to come observe my procedure and make recommendations. I applaud your attention and commitment to improve your practice.
We too are a single person per day PICC team. Partly due to budget and fluctuation in demand. I also have that problem with working in some very cramp spaces and unable to tie back of gown. I have had to move an area outside of work space to fully tie my gown, but it doesn't happen 100% of the time. Thank you to all that have provided CDC guidelines and other supporting information for the need for two person teams. I will once make a case for need for a PICC TEAM (not PICC person) approach.
Debra Rivie RN VA-BC
Long Beach Memorial Medical Center
Long Beach, CA
Debra Rivie RN VA-BC
Long Beach Memorial Medical Center
Long Beach, CA
Debra,
Currently and for the last three years, the patient's primary RN steps into to the room for the time-out, help with gowning and observes until the dressing is applied (about 20-25mins). I get pull back every time there is a new manager or director of the unit. After seeing the documentation below they understand it is best-practice. I would like to train our CNAs but they are not allowed to document the checklist.
R. Terry Jones, RN, CRNI, VA-BC
Memorial Hermann Northeast Hospital
Humble, Texas
When your a one person Vascular Access Team...you should not tie the gown in my opinion. I tried it last week and it was impossible. However, another factor is if you leave the gown untied, the cardboard tap stays in front of you, waist high. If you pull that tab in an attempt to tie, it falls and dangles. NOW it's not sterile. If you have 2 people then sure tie the gown, but if you don't I would just put it on and leave it. There is no evidence showing that by NOT attaching the tie you are causing a higher risk of infection. If anyone has a study that shows that specifically, please let everyone know.
Jack
I don't think anyone is going to do a study to determine if wearing a sterile gown improperly is still safe. Good luck getting that past an IRB!
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
Exactly!!..
I guess my point was that you will never find evidence showing that using a medical device improperly is acceptable. If your patient develops an infection subsequent to your insertion and it is revealed that you did not adhere to established sterile technique by failing to use a medical device (sterile gown) according to the manufacturer's instructions, it is possible you can be held liable for the morbidity. I live with two lawyers. That's all I'm saying.
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
Hi Keith,
I guess that is where we differ. I think your lawyer friends would have a difficult time proving that not tying your gown in the back is somehow leaping to improper use of medical device. I know what your trying to say. But as long as the gown stays draped in front , the back is never sterile tied or not. That would be tought to prove that by not tying the back you misused equipment therefore caused harm to the patient. That is a stretch to say the least. But as your friends will tell you...you can sue for ANY reason. But I have to tell you I would love to hear how they argue that!
Jack
In a nursing or medical malpractice case, the goal is never to "prove" something did or did not happen. The goal is to demonstrate that "more likely than not" the deviation lead to the outcome. So the weight of evidence must only be tipped toward the deviation or 51%. I am frequently reminded of this in the legal cases where I testify. So this scenario would come down to the testimony of the experts. Given the evidence found in the gown manufacturers instruction for use, numerous other guidelines and standards, the plaintiff expert would have able to state that it is more likely than not that failure to tie the gown led to the ties and/or the back side of the gown falling forward and contaminating the sterile field, which then led to contamination of the catheter and then to the infection. So the burden is not absolute proof, but just more likely than not! 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
Which Regions of the Operating Gown Should be Considered Most Sterile? is a good study regarding sterile gowns.
Where are the nurses who take care of these patients? They are the ones you should be contacting to assist you - "if you want the PICC, you have to help me!" Others have already covered having a second RN to observe and audit the procedure. Educate your nursing staff that this is a requirement - and don't place the line until you have the resources you need to do it safely.
Wendy Erickson RN
Eau Claire WI
Wendy,
Good point....not possible. We have already discussed this and the floor nurses do not have time to be in the room with us. I agree with you. However, I would like to see institutions implement 2 person PICC teams. This addresses all issues at once. I wish it was as easy as "come into the room and stay with me observing"...believe me I do!
Jack
assuming you're in a hospital. What about mobile vascular services? Also - I could not even count the number of times a nurse or a CNA contaminated my sterile field. Less movement about the room is better too, often the nurse has to leave and come back. Thanks but no thanks, some of the "help" is more trouble than help. My untied gown is surely less risk than the second person brings.
A trained assistant would be a dream come true. I won't hold my breath.
Your untied gown is FAR less risky. Folks, we are all smart people. If we use common sense these kind of issues would not come to surface. How in Gods name are you standing at the bedside inserting a sterile catheter, all sterile equipment in front of you gown on and tied at the top. How is it even possible that you could contaminate the field because your back is open slightly down the center, of your back. Have we stopped thinking like sensible clinicians?......Just stand back and let that go around your head. really?...you really think that will cause the patient harm????. I am discouraged how we as nurses speak on issues. It doesn't give this old guy hope, that we as a group are getting smarter...I really need to feel that. I want to leave nursing thinking I left it better than when I started 25 years ago. But then these kind of issues come up.
Lynn, you said to me...I'm not hear to debate of argue?....that precisely why we are all here on these forums...is to debate. Nurses all do things differently. As a nurse I hope I'm smart enough to think , assess, adapt. Every case is a learning experience and I hope we all have that attitude. Standards of Practice?? Is that supposed to mean we cookie cut all patient care?...I applaud the clinicians who can think on their feet and not be tied to some manual telling you how to do something.
And to answer the original question....Your gown is fine just connected at the top....next we'll be talking about what color is best. I have always read comments on this blog. Not because I want to be told how I should be doing something. I'll let my experience speak for itself. I read because I want to see how the people in the trenches, the ones doing this day in and day out are performing. I like the difference in practice. hell, I take things I learn from others nurses all the time. But that's what I would like to know. I really treasure the clinicians experience. So please, keep writing....and I hope we will continue to "argue and debate" issues.....we're nurses that's what we do.
I still remember the "trench" nurse who taught me to tear the fingertip off my glove. I remember the nurse to told me that when you swab with alcohol prior to starting an IV, you only swipe once. Swiping any more than that only spreads germs over the site. I remember the chemo nurse who first taught me that you only need to wear chemo gloves when you are pushing chemo. And now I will remember the nurse who told me that it is not necessary to tie my sterile gown because the opening is on the back. (Why do the manufacturers even bother to put string ties on it??)
I appreciate your sentiment to learn about others' practices, and I value them to an extent. I come here to learn evidence-based practice and how the evidence (not the so called common sense approach) applies to unique situations. I respect that you (and others who happen to work in less-than-ideal conditions) believe that sterile gown ties are unnecessary. Noted. Let's move on.
Finally, I don't come here to argue or debate. I come here to learn. I only pay attention to evidence. Opinions, even those who come from nurses who have practiced longer than I've been alive, are vaguely interesting at best. As I said, I learned a lot of really bad practices from some well meaning, experienced "trench" nurses. By discovering the "Standards of Practice," I learned that those practices I mentioned above are all bad ideas. Practice SHOULD be standardized. This is how we reduce med errors. There needs to be a standard against which an industry can be judged when something does go wrong. Unfortunately too many problems happen from people trying to exercise their "common sense." This whole back-and-forth on this simple topic leads me to ask why the clinician didn't simply go to their Infection Control department and express concern over less-than-ideal circumstances in which to perform a sterile procedure. We wouldn't allow surgery to take place in these sorts of circumstances. If your room is too small to tie your sterile gown, you need to move rooms! If you are being "forced" to work in unsafe conditions (by the way, single member PICC teams are unsafe, per SHEA Compendium 2014, Period), quit. You're fooling yourself if you think decades of experience trumps established, evidence-based practice standards in a court of law. And even if you still disagree, please understand that this is not the "Ask Insert Name Here" website, though your opinions are as valid as the next person's; it is a wonderful venue frequented by some of the most published names in infusion therapy designed to exchange ideas that are grounded in evidence.
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
Keith,
I wasn't trying to be harse, I was trying to be truthful and most of all sensible. I may be wrong here, but by your response I'm guessing your a relatively new nurse. So, assuming such, here's my advice to you. Evidence based practice is a buzz term so we as nurses can sound smart. Remember nursing care plans??...Evidence based practice , to me, is for my information. It is for me to look at the study, blend it with what I know, and determine if it's worth implementation. We just had a meeting with our Infection Control and asked in the last 2 years, how many CLBSI's or CRBSI's were attributed to the PICC insertion....answer:NONE. that is 4000 gowns, procedures, all the things that go along with how I taught my nurses to insert PICC's and not one infection. 4000...is that a big enough sample size. I know for a fact your "learning " from studies with far fewer subjects. So, should the whole Vascular Access community insert lines exactly the way I teach it. No they shouldn't.
And you my friend, should learn that evidence based practice is decided by ...wait for it...PREFERENCE. Who decides which study changes practice and which study doesn't. Who is the PICC GURU that makes that decision?. There is a great study published as we write, that states that peripheral IV's are BAD....I mean BAD...even in the hands of IV teams....BAD!!. Yet go to any big Vascular Access team and they put in a ton of peripherals. So, why hasn't that changed?....Now in PRACTICE , I know that to be true because I see it everyday. So we have PRACTICE + EVIDENCE=NO CHANGE. Point is don't come here to be told how you should practice, come here to expand what you already do. Come here to validate what you do works. Come here for ideas.
And don't knock experience...someday you'll have 25 years of it and you won't think it gets trumped by Evidence based studies.
Ok...I don't want this to turn into an attack on each others practice. So, keith if you think I'm being too harsh I apologize. I just get my feathers ruffled when a nurse comes to us with a concern about her gown, and instead of offering her support, we tell her she's doing something wrong. No one likes to think they are doing anything to hurt a patient. So, I was just trying to come to her defense and point out that many, many insertions are going on without the gown being tied and there is not a backlog of cases of nursing negligence. Well, maybe there is?..lol. I just don't know about it. And yes, I agree there should be standards but I was just trying to point out that nurses adapt and change little things about how they practice, and they are not affecting the safety of the patient it's just a different way.
So, your right Keith, lets move on......
Jack
I still want to know who that PICC GOD is that makes the big decisions on which study gets implemented. Do you think that job pays well?