I have a question about changing Injection access caps for central lines. In the INS book under injection caps it states to change per hospital protocol or at least every seven days. However, under site care and maintenance it states that “Change of add-on devices such as, but not limited to , extension sets, filters, stopcocks,and needleless devices should be changed with the administration set. I was wondering if you could clear this up for us.
Thank you,
Krista Rein, BSN, CCRN
The maximum length of time that you should use any needleless connector is 7 days according to the 2006 Infusion Nursing Standards of Practice. This would apply to connectors on catheters used for intermittent infusions. CDC guidelines state to change everything at the same interval, which is no more frequently than 72 hours. However, CDC guidelines do not make a difference between primary continuous administration sets and primary intermittent administration sets. It is my firm belief that a needleless connector is not needed when there is a continuous infusion. This adds additional connections that can come loose, adds costs, and has the potential to promote bad practice by making it far too easy to disconnect the set from the catheter for nursing convenience. Continuous infusions should only be stopped for a few seconds to change the set at either 72 or 96 hours. We now have additional information about the risk of infection associated with these connectors, so 7 days is probably far too long to have them remain in use. I would change them all - whether used for continuous or intermittent infusion - on the same time interval, which would be the same as the sets. Sets used for intermittent infusion, however, should be changed every 24 hours and should not be extended beyond that due to the risk of the male luer end becoming contaminated with each intermittent use. There are no studies whatsoever that have assessed the infection risk associated with intermittent sets, therefore CDC does not recognize a different while INS takes a conservative and cautious approach to patient safety in the absense of such studies.
In the text book you are probably looking at 2 different chapters written by different people and their interpretations are leading to your confusion. Since I do not know which chapters you are referring to I do not know if you are reading something that I wrote or not. Let me know and I will try to provide more clarity if this did not clear it up for you. 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 the INS book S35 Injection assess caps it states to replace them every 7 days. However one of our IV team nurses state that on S48 Adminstration set changes that it also talks about changing of add on devices, extension sets, filters, stopcocks, and needleless devices should coincide with changing of administration sets. She takes this as changing of the access caps.
I believe that opening the system at the access caps every 72-96 hours will increase infection rates because you are opening that entry point every 3 days vs 7 days. I can't find any liturature on changing access caps every 3-4 days. Everything that I'm reading is every 7 days.
Thank you,
Krista Rein,CCRN
You are referring to the INfusion Nursing Standards of Practice. When you said "book", I assumed you were referring to the new edition of the textbook. All tubing and add-on accessaories, including all needleless connectors must be changed at the same interval. Check the CDC Guidelines - that is your reference. Your idea of not opening the system is not valid - change it all at the same interval!! 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
THen the INS standards of practice where it talks about access caps need to be changed every 7 days is wrong information? Is the CDC the only place where you can find this information? I see a difference between access caps and needleless ports. I see a needleless port as an injection port that is used over and over. Where as the access port is only accessed by the tubing direct to the central line. Is this the wrong thinking. I can find manufacturer guidelines that state 7 days for access ports. I just can't find the information to support changing the access ports every 72 hours.
Krista
The INS information was not wrong when it was written, but there will always be changes in practice due to more studies becoming available. The confusion is still coming from the distinction INS makes between continuous and intermittent sets while CDC does not recognize this difference. All caps and injection ports currently used in clinical practice are needleless connectors. Due to OSHA standards, we should not be using anything but a needleless connector. In fact, I have a manuscript being published in the Jan-Feb issue of the Journal of Infusion Nursing about terminology where I am calling for a consistent use of the term needleless connector. There is much confusion about these devices because we are using do many different terms. All injection ports are needleless connectors, regardless of whether they are on the catheter hub or on the IV set.
Biofilm grows inside these connectors and it reaches a steady state within about 5 days. After that it can break off and produce catheter related bloodstream infection. Thus the need to change more frequently than 7 days. 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
Also good to look at the manufacturer's Directions For Use as to what they recommend. Some say to change connector every 24 hours, after blood draws, or every 24 hours if infusing TPN.
According to the new CDC 2009 Draft needleless connectors/caps should be changed no more frequent than q72 hours. Here is the information from the draft:
B. Needleless intravascular devices
1. Change the needleless components at least as frequently as the administration set (160–162, 164–167). Category II
2002 - Change the needleless components at least as frequently as the administration set. There is no benefit to changing these more frequently than every 72 hours [87, 328-334].
Nancy Moureau
PICC Excellence, Inc
Nancy L. Moureau, PhD, RN, CRNI, CPUI, VA-BC
PICC Excellence, Inc.
[email protected]
www.piccexcellence.com
Nancy's highlighted statement is the new addition with this draft of the CDC document. The first sentence has always been in the CDC document. 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 completely agree with Lynn Hadaway's statement: "we should not be using anything but a needleless connector."
However, according to lines 1078-1079 of the CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections draft states "the split septum valve is preferred." The split septum device in the cited references can be accessed with a needle. Split septum technology is old, and requires hospitals to purchase multiple parts to access it; most importantly it can still be accessed with a needle, so how can the CDC recommend old technology that goes against OSHA regualtions?
Comments on the draft can be posted at [email protected] before December 3rd. I would recommend that everyone review these guideline and make your voices heard.
I don't see the split septum as moving backwards at all. There are newer products that exhibit the preferred mechanism and not require a blunt access or needle access.
It is harder to respond since we can't see the other posts. This is an FYI for Sarah.
Gwen Irwin
Austin, Texas
The statement in the draft guidance is based on the device used in the cited references. The split septum device used in the cited references was the external activated blunt cannula technology (Interlink). The guidelines are not recommending the newer versions of split septum because these devices were not studied in the cited references. To interpret the guidelines as such is incorrect. Once again, the CDC draft is recommending that we go back over a decade in device design technology and use a product that does not completely meet OSHA requirements.
You must review the cited references to clearly determine the device they are suggesting.
I agree that referencing the articles listed in the CDC guidlines are the best. But, after reading a 3rd time. I don't believe that the references are about interlink.
The guidelines are referencing split septom devices. Look at the reference article and it is talking about the Micorclave connector and others that qualify for their definition.
The statement in the draft guidelines are refemcomg the use of split septum devices.
Gwen Irwin
Austin, Texas
I must disagree with your assessment. When we refer to a split septum needleless connector, we are referring to the way the nurse interacts with the device or a split septum on the top of the connection surface with either a blunt plastic cannula or a male luer of a set or syringe to pass through that split septum. The group of needleless connectors designed with a reversed, internal blunt cannula are considered to be mechanical valves. These are accessed by the standard luer mechanism as other mechanical valves. The brands in this category or Clave, MicroClave, and Invision Plus. Deb Richardson and I have an article being published in the Jan-Feb issue of the Journal of Infusion Nursing about these designs. According to the published studies, CDC is saying that the split septum/blunt cannula systems have the least risk of BSI and are the ones they are recommending. Whether you agree with this assessment or not, we can not confuse the external blunt cannula with the reversed internal blunt cannula. 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 looked at the reference article used by the CDC and it wasn't the old version of split septum with the blunts.
Gwen Irwin
Austin, Texas
Be careful and do not let the CDC draft confuse you -if we are bringing up devices that are not covered under the wording "split septum" according to the CDC draft you must also include the luer activated split septum (the Qsyte) in this discussion. The luer activated split septum was not studied in the references which were used to make the split septum recommendation.
Three of the cited references used to make the split septum recommendation actually studied split septum, the other one did not. All of the split septum references utilized the same blunt cannula activated Interlink device. The CDC draft recommendation and its cited references do not support the use of any of the newer split septum technologies, the cited references only looked at external blunt cannula activated split septum technology. Internal cannula activated mechanical valves and luer activated split septum devices were not studied. So as clinicians we must be careful not to confuse the issue and we must take evaluation of needleless connectors into our own hands. The CDC recommendation would have be better if it stated: Needleless connection systems should be evaluated thoroughly prior to implementation. A check list of design features to analyze and review would have been more appropriate:
1. Can the access surface be thoroughly disinfected?
2. Do gaps, depressions, and others areas exist that can not be reached
during reasonable disinfection procedures?
3. Does the fluid path contain areas which fluid could be trapped?
4. Can the device be thoroughly flushed?
5. Is the device clear permitting completed visualization of fluid path
during flushing?
The split septum device currently recommended in the draft is old technology which still permits the use of a needle and requires additional parts to access the device. Unless you are still boiling and resusing your needles, you need to be aware of new technologies and practices.
My advice to clinicians researching this topic is there is a tremendous amount of research out there not covered by the CDC draft. Get it and review it. In addition, get the devices and do your own research bylooking at them carefully and seeing how they operate.