We are in the middle of developing our CVAD policy. Once again the issue of what kind of technique to use for accessing ports has come up. Many of our chemo departments do not use sterile gloves for access. After cleansing the site, they secure the port with their hand with a clean glove, access the port then apply sterile dressing. They try to not touch the skin over the septum with that clean glove.
It seems that there are a couple of issues that lead the chemo nurses to use clean gloves to access:
1. The following guidelne from CDC: "Basic Infection Control and Prevention Plan for Outpatient Oncology Settings" which advises to "wear clean or sterile gloves (additional precaution per INS includes use of sterile gloves and facemasks)" for accessing a port. This is why our chemo dept does not want to use sterile gloves.
2. There seems to be confusion over the term "aseptic technique". Is aseptic the same as sterile?
Our concerns:
1. It seems odd that we would follow INS Standards ie sterile procedure throughout the hospital but for chemo patients who tend to be neutropenic we can use a clean technique.
2. The potential problems you may be facing when you place a sterile transparent dressing over a clean area and leave it for 7 days
Is it true that INS Standards trump anything else including the above guidelines?
Any advice on how to sort this out would be greatly appreciated. It is our belief that INS Standards should prevail for all port access procedures but there is a lot of resistance to this.
Thank you!
The concept of one document "trumping" or being more important than another document is a bit misleading. Yes, the Infusion Nursing Standards of Practice are constantly used for many purposes including writing facility policy and procedures, performing QI/PI projects, and measuring the nurses performance in a lawsuit. When it comes to a lawsuit, all documents are considered together to establish the standard of care, or what any reasonable and prudent nurse would do in the same or similar situation. The experts on each side would give their opinions. Most cases settle out of court, but if the case did go to court, it would be a matter of which expert was the most believeable by the jury. People on the jury are not typically healthcare professionals, so they have no means by which to put more weight on one document or another. It all comes down to which expert is the most believeable by the jury.
When we wrote the standard of using sterile technique for accessing implanted ports, we looked for any data that could be found and we contact ONS nurses for their input. Based on the limited data and the fact that these patients are immunocompromised and because this involved inserting a needle through the skin (which can never be made sterile) into the implanted port, and this port is critical for the patient's care, we thought it was appropriate to state sterile technique.
The CDC statement is based on dressing changes, not accessing an implanted port. I do give them credit for referencing the INS standards though.
I definitely agree that your standard must be the same for inpatient and outpatient. I also agree that if sterile technique is not used for accessing, then why are you using a sterile dressing?
If this were my implanted port, I would expect, demand sterile technique each and every time. I strongly stand by what is written in the INS standards. I would advise that this question be taken to your infection prevention committee and get their input, but I would work toward the same process for all immunocompromised patients.
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 will first state this: Port infection are on the rise in the literature recently as stated in the MMWR
ONS based the decision for clean technique on one paper written by an author of the ONS recommendations, who is well respected at ONS. Her statement was there was no difference statistically, with or without sterile techniue. I have read the supporting doucment and the infection rate was higher without sterile technique and it was no where near zero. To get to zero one must consider how to get there. Do we accept a paper supporting non sterile technique to access ports where the rate was not even close to zero as acceptable. This study was also not prospective and randomized. It is cheaper to access non sterilly so there is incentive to do so if one is not responsible financially or by public reporting for CLA-BSI.
I do not hold this one reference as valid proof of no need for sterility to access a port.
I hold by the INS positon standards of care for sterile technique to access a port. Hospitals are holding to sterile technque from what I have seen. Physician offices do not have to report infecitions to any body publically. I might consider the culture every port that comes into a hospital. You own it once it enters your facility. You have no idea of where it has been.
Kathy Kokotis RN BS MBA
Bard Access System