Forum topic

Could you let us know what the study is and where we can find it.   Thank you.

Marcia

I think your ID nurse refers to an article by John Hopkins Neonatal ICU, There are quite a few better articles on adult population that saw no increase infection w/ the use of positive pressure valve.

One of the best articles on Hospital Acquired Infectios I read lately was publish in Infection Control Today (ICT) by Cynthia Grube called "Small Steps to Big Benefits at the Bedside" it was posted on 05/31/2007.

Every hospital manager and emplyee should read this article.

The "Hopkins" article by Lisa Maragakis, et al does report up to a 60% increase in CR-BSI with a positive pressure valve.  The increase was noticed first in the NICU but was also seen throughout the hospital.

http://www.icumed.com/Docs-Clave/Maragakis%20ICHE%20-%202006%20Johns%20Hopkins%20SmartSite%20Plus%20Infection.pdf

Hope this helps.

-Tom

At the present time, there are at least 4 articles published with a similar scenario - product A being used; product B brought in; over the next few months a rise in CRBSI is noticed with the only change in practice being the change in needleless devices. 

 This raises many issues about the design of these devices and the nursing practices in caring for them - adequate cleaning of the device, management of the IV tubing, frequency of changing the device, etc. But it does not confirm for me that product B actually carries a greater risk of CRBSI. The study that would demonstrate that - a randomized controlled clinical trial, preferably multiple sites, has not been done yet. 

 So to address the concern of your infection control nurse, I would ask if your facility has a documented problem with CRBSI? If so, it is in your best interest to work on changing that because your facility will not longer be paid for hospital acquired CRBSI after 10-1-2008 from Medicare. There are numerous things that must be considered along with the needleless devices. I would not expect a simple change in devices to prevent your entire problem. Lynn

Positive pressure connectors have been identified with increased CRBSI.  The issue with positive pressure devices is two fold  The first is fluid pathway design.  In order to provide a positive push with disconnection amechanism inside the connector had to be designed that would provide first a negative pressure on connection (causing reflux) and then the positive pressure on disconnection.  This is the law of physics for every action there must be and equal and opposite reaction.  This mechanism means that the fluid pathway is tortuous.  Just like a tortuous river has eddies, the connector fluid pathway has deadspace.  This deadspace is filled with fibrin with the first withdrawal of blood (vein verification) and continues to build with subsequent withdrawals.  The second design issue is the free moving septum with a single microbial barrier.  This design is required to enable the septum to move back in place.  However, with access any microorganisms left on the surface are pushed into the connector with the slip tip of the tubing or syringe.  Bacteria know there is somewhere to stick when the fluid slows (much like the fish in the edy) and stick to the fibrin in the deadspace.  Since deadspace is just that dead (unable to be flushed) the bacteria colonize and multiply.  If the colony grows large enough it can be broken off with flushing.  Guiy Cook from Bacterin presented a wonderful poster and presentation at the recent AVA meeting in Phoenix.  To see a copy of his work go to rymedtech.com.  His study shows that with increased priming volume and deadspace there is increased bacterial colonization of the connector. 

The new designed InVision-Plus Neutral connector by RyMed Technologies has a protected fluid pathway, zero fluid displacement with connection or disconnection, and can be used with Saline only.  It has a straight fluid pathway, zero deadspace, and 0.027 mL priming volume.  It has two independent microbial barriers.  The slip tip does not enter the fluid pathway.  In the study by Guy Cook it was shown to be 93% to 99% better than all other connectors studied.  The zero fluid displacement feature minimizes fluid reflux to physiological (coughing, blood pressure, vomiting etc.) only.  When changing connectors, moving to a protected fluid pathway offers lower CRBSI.  Again a poster at AVA presented by Sophie Harnage discussed a central line bundle that included the InVision Plus Neutral connector with outcome results of zero CRBSI for 15 months in a community hospital.  Her work spoke to the issue of protecting both the extraluminal catheter track and the intraluminal fluid pathway. 

Denise Macklin

Tony West, RN, CRNI

Healix, Inc.

Cell: 214-674-4848

And now comes the article in the last issue of JAVA. The author presented this oral abstract at the AVA meeting in Pheonix.

Don't be in a rush to chuck your valves, or any other valve yet, until you read that article. Finally someone addressed the issue that everyone was skirting. That of failure to swab/ineffective swabbing, that we know from other studies, goes on. Read the article, it is worth the time. 

Tony West, RN, CRNI

Healix, Inc.

Cell: 214-674-4848