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daylily
Help needed with tubing change policy/education

Our current hospital policy is to change IV tubing every 96 hours, peripheral IVs every 96 hours, lipid tubing every 24 hours.

I want to change this based upon INS standards.  I was told by a CRNI that peripheral IVs can extend to 96 hours if you do not have any infection problems.  Anyone know?

If a continuous infusion becomes intermittent the tubing should be changed in 24 hours.  How do you monitor this?

Let's say a patient is receiving a continuous infusion and the tubing is labeled to be changed in 72 hours (based on INS).  The patients peripheral IV requires changing within the first 12 hours.  Do you re-label the tubing to 24 hours from that point?

Any examples of this standard in practice would be appreciated.

lynncrni
INS standards regarding

INS standards regarding tubing changes for primary and secondary continuous sets is "no more frequently than 72 hours." This is the exact same language as the CDC. So you can extend to 96 hours and be practicing within both INS and CDC statements. 

PIV change remained at 72 hours in the standards. CDC says 72 to 96. We did not feel comfortable going to 72 for the standards because this document must be applicable to the lowest common denominator- think of the small rural hospital without all the services as other hospitals. If your hospital has internal QI data that extending your dwell time to 96 hours is not putting your patients at risk for complications of any kind, then you can go to 96 h based on the studies avaiable.

When you convert a catheter from continuous to intermittent, I would discard all that continuous tubing and begin a new tubing for 24 hours for the intermittent use. Or simply discard the continuous tubing and open the new tubing when the next intermittent does is due. All tubing should be labeled, either the time up or the expiration date and time and the assigned nurse is responsible for changing it. I would never recommend relabeling any tubing, just simply starting over with new tubing.  

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

daylily
I recently brought a

I recently brought a recommendation to change our tubing hang time to our infection control sub-committee.  Everyone present seemed agreeable, however, defining what is and isn't allowable will be a challenge.

How do you handle an existing continuous medication that was recently hung through a peripheral IV (that needs to be removed) now that a new PICC has been inserted?  I'm thinking of a PCA.  My feelings are that everything... solutions, tubings, meds should be new.  What is the general practice?

Gina Ward
Gina Ward R.N.,

Gina Ward R.N., C.P.A.N

 

Are you saying the recommendations for intermittent infusions ( antibiotics every 8 hours for example, when nothing else is connected to the patient) tubings must be changed every 24 hours?   

 

 

 

Gina Ward R.N., VA-BC

lynncrni
That is exactly what I am

That is exactly what I am saying and what the INS standards have always stated. There is no published research on intermittent tubing whatsoever, therefore the standards have always remained to change intermittent tubing at 24 hours. CDC does make a difference between continuous and intermittent tubing, but INS does. However CDC does state that all needleless connectors must be accessed with a sterile device. No one will ever be able to convince me that an intermittent tubing used for 72 or 96 hours is still sterile on the male luer tip. I even have doubts about it being sterile after the first dose. For years now we have been blaming the outbreaks of CRBSI on needleless connectors, however we have failed to look at the other side of the system - the tubing we are attaching. How often do you see these left open, or with blood back up into them or looped and attached to another injection port. None of these are acceptable practices.

 Regarding the tubing for a new PICC. I would always start with new container and new tubing when I put in a new PICC. I would never recommend using tubing that has been attached to any other catheter - peripheral or central- regardless of how long it has been in use. 

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

daylily
Upper management has agreed

Upper management has agreed to change our intermittent tubing to 24 hours based on the INS statement.  Now for those of you doing this, I need advise when a continuous connection is interrupted.

1. How do you communicate that the continous nature was interrupted and the tubing should be changed? I can see changing the tubing with the next bag change.  Do you place something on the IV bag to let the next shift know when they change the bag?

2. Do you consider a continuously infusion intermittent if the peripheral IV needs to be restarted?  This could be on day 1 with a new liter of fluid hanging.

 

momdogz
1.  When the tubing is

1.  When the tubing is disconnected, throw it away.  If I find a disconnected set in the room, I'll either talk with the RN, throw the tubing away, or both.  From my experience on the floors, I'll bet that using stickers on the bag and tubing would not prove to be very effective way of communicating when continuous tubing that is now 24 hour tubing needed to be changed (partly because I don't think nurses would 'resticker' the tubing when disconnected).

2.  New site = new administration/infusion set.  Another practice difficult to change, and I know not everyone is doing this.

We have a large hospital, and education re: this has been a challenge (partly because in the beginning, most fell on me).

Nursing administration and infection control are fully behind this policy and practice.  I tell the RNs that it is policy, it is mandated by upper administration, and that the cost of tubing/add ons etc. is much less than a BSI or septic phlebitis from any vascular access device.

I still find pockets of resistance, but when presented with all of the information that Lynn discusses and clear evidence about BSI, biofilm, etc., no one has yet provided a successful argument against it.

When I was looking for assistance with this issue in an earlier thread on this website, Lynn said: "Nobody likes change but a wet baby."  I think that's the gist of it - change is hard (although I'd argue that older babies can hate diaper changes too, but probably because they're starting to get set in their ways already!).  "Because we've always done it that way" mentality has some staying power, but when you invite awareness about a problem, present solutions, and encourage involvement and accountability from the bedside clinician, change WILL happen.

I'm relieved to see my efforts paying off now - hang in there.

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

bsherman
Site Changes

Along the same lines, if a peripheral site is d/c'd and picc line or other piv initiated all tubing is to be changed.  What is everyone doing about the meds that were just hung for instance?  are you requesting new bags from pharmacy or re-spiking with new administration set?  This seems to be our challenge as we have a waste not want not attitude, expecially on the expensive meds.

lynncrni
 I answered this question on

 I answered this question on my company's Facebook pages just a few days ago. Here is that answer pasted below:

There are no established standards or guidelines about changing the fluid container at the time of inserting a new catheter. All tubing must be changed as you mentioned and it would be preferable to hang a new fluid container on new tubing with a new catheter - both peripheral and central. We do not have any recent studies on fluid containers and the frequency of change for them. If using plastic bags, removing the old tubing spike will allow room air to enter the container. If using a glass bottle, room air is already entering the container through a filter on the air vent and removing the spike will allow unfiltered room air into the bottle. Opening either container will allow dust particles and other particulate matter floating in the air to enter the container. So I am wondering why new fluid containers were hung so close to placing the new catheter in the situation you described. Did the primary care nurse not know that a PICC was scheduled to be inserted? Did she/he not realize the cost issues involved? The costs from the pharmacy seems a little exaggerated to me unless these containers were compounded with many medications. Also how many filled containers were actually discarded? Your description sounds like more than one. Maybe you can use this experience to evaluate your PICC insertion practices regarding communication with the primary care nurses about when to expert you. Also use this as a teachable situation for the primary care nurses. A new catheter should have a new system and it is preferable for that to include a new fluid container. That might not always be possible but if the primary care nurses knew you were on your way to insert a PICC and there were no rate-sensitive, critical drugs being infused, the overfill in the first container could be used to KVO until the new PICC was inserted and ready for infusion with a completely new system.

Lynn

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

bsherman
Lynn,   This has occurred if

Lynn,

 

This has occurred if patient had PIV that went bad then PICC was ordered (trying to assess these types of patients to get PICC's placed earlier, ours is a new program and we are getting there).  also per INS standards if PIV site is rotated due to infiltration, accidental dislodgement or other reasons then new tubing is also required, in that situation nurses have no forwarning that a new site is going to be needed.

lynncrni
 Each situation is different.

 Each situation is different. So you just have to make the best decision for each patient at that time. If I had a liter fluid container that was less than half full, I would probably change it along with all the tubing. If there were critical meds compounding in that fluid container, that may change the situation. If bag was almost empty and one catheter went bad, I would certainly not open a new container until the new catheter was placed. The point is the research on fluid containers is very old and practice along with design of those containers has changed a lot. So we do not have an evidence-based answer to this. All nurses should be taught that the overiding goal is to have a whole new system with any new catheter, including all tubing and fluid container. Many times that may be possible, but there can be some exceptions especially when there are critical meds in the container and a new one is not yet available from the pharmacy. Lynn

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

bsherman
Thank You Lynn, that is the

Thank You Lynn, that is the way I have been approaching it but nursing of course wants black and white answers.

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