When you have a patient on TPN do you have the nurses to change the cap at the same time they are changing their tubing and filter? We have our nurses to change the cap as well as the tubing and filter for any type of CVC. What is everyone else doing?
If the patient is on continuous TPN I would make a direct hub to hub connection and would never place a needleless connector or cap inside the line. If the patient is on cyclic TPN, I would change the needleless connector at least once per week. Every 3 days is also a frequent change protocol or as CDC recommends change at the same interval as your policy for changing IV administration sets.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Stephen Harris RN, CRNI
Lynn,
In theory I agree with hub to hub connection for continuous infusion but do you have a safety concern for the hospitilized patient who may decide to unscrew their line "just for a second" to wash up. I have seen this happen too often and feel clinically it is safer to use a quality cap. As always looking forward to your opinion.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
For continuous infusions of any kind, I do not believe it is appropriate to stop those infusions for any reason. Stopping them will alter the patient's therapeutic response to whatever fluid or med they are receiving. I realize this practice of stopping continous infusions to allow for bathing, ambulating, etc has become common practice, but I do not think it is appropriate practice. If the patient did not need those fluids or meds, they would not be infusing. Continuous means constant without interruptions. These interruptions, along with improper use of other intermittent tubing beyond 24 hours, could be a major reason for the CRBSI rates. Everyone is blaming the needleless connectors, however I believe a huge part of the issue is the way we are mis-managing administration sets.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Beth,
Several things come to mind when reading your post. The ultimate goal is to maintain a closed system or keeping the system as closed as it can be. Having said that, if the TPN is continuous then I would think you would change the cap in accordance with the manufacturers recommendations. The FDA has put some limitations on what manufacturers can recommend now and many of the manufacturers will state 72hrs or per your facility's P&P. And, in accordance with the current INS standards, you typically change TPN tubing every 24hrs if there is lipids and 72hrs if no lipids. Here are some things I think about when developing these policies. The continuous presence of a high dextrose formula can contribute to colonization of bacteria and infection, likewise, the more we open and manipulate a device, the more we open the patient to infection. If your TPN is inclusive of lipids then you must consider that as well. So based on your patient goals, health status and expected outcomes, what is the best formula for this?
Manipulate the system the least number of times while making sure that the line is clear and functional and look at the recommendations for cap changes and the literature on the different types of caps and how they are made, clear vs not, complex fluid path vs straight path.
Hope this helps