I am refering to the needleless connector; we wish to know the "best practice" when hanging TPN in the hospital. We do change the tubing with each bag.
In my opinion, best practice is to totally eliminate the needleless connector for ALL continuous infusions including PN. These devices were designed for intermittent infusion and not intended for use in a continous infusion set. I would connect the luer lock set directly to the catheter hub, which is what was done prior to these devices being introduced. There is no research to support their use in a continous infusion of any kind. they are a known source of contamination leading to CRBSI. One reason I have been given is that the presence of a connector prevents opening the catheter lumen when changing the IV set. CDC states that the connector should be changed at the same interval as the IV set, so you still have to open the lumen. So there is no benefit to having these connectors inline for any continuous infusion. In fact, I also think that foster bad practices by allowing the nurse to interrupt the infusion for patient activity such as ambulation, etc. They give no thought to what is in the infusion, how long it will be disconnected, how to manage the disconnected set, and how to correctly ensure it is reconnected. This is done without policies and procedures and I think it is dangerous practice. Lynn
This makes sense Lynn. However, on more than one occasion I have been called out to a facility because the nurse had removed the needleless connector and connected the IV tubing directly into the PICC hub, only to find they (and myself) were unable to remove the tubing. It seems to get stuck. On one occasion, I used every technique I could think of....I eventually resorted to an over the catheter exchange.
Although I could see a case for not useing a needleless connector on an inpatient with a continuous infusion in a closely monitored setting (ICU or MAYBE stepdown) I would caution against it in any other setting inpatient or outpatient. The needleless connector does serve a purpose. If the infusion is stopped for any reason, accidentially or purposefully, or the infusion tubing becomes disconnected from the hub of the catheter for any reason, intenionally or accidentially, the needleless connector protects that hub from contamination and ingress of germs, and also prefents the patient from bleeding through the catheter if the catheter is not clamped when the separation occurs. Not every patient is A and O x 3 with the ability to clamp the line in case of a problem.
The CDC Guidelines do not state to NOT use a needleless connector in any instance, and state the connector should be changed with the tubing, every 24 hours.
I interpret the CDC guidelines in a totally different manner. There is evidence that changing the NC more frequently than 72 hours increases the risk of contamination and infection.
Also, why would a luer locked IV administration set connected direcly to the catheter hub have any greater risk of accidental or purposeful disconnection than a needleless connector with the IV set attached to the NC? Why would 2 luer-locked connections be better than 1? That makes no sense to me, especially since there is absolutely NO evidence to support the use of an NC within the infusion system for a continuous infusion. The new SHEA Compendium CLABSI chapter points out this lack of evidnece for their use in a continuous system. These were designed for intermittent connection and it is my opinion that is how they should be used. Lynn
I agree with Chris on this point. I think it's a huge risk for home infusion patients to not have NC on their lines. And as a point for in-patient use, as a pt myself who has received TPN both in-patient and out-patient I think it's also a risk for in-patient use. Lines are disconnected in-patient for various reasons such as allowing pts to shower/bathe and even for transportation. Now you can say that nurses should be taught and it should not be an issue in-patient but I can tell you from experience it is. I was a patient in a Level 1 trauma center and frequently had to correct floor nurses who would disconnect by TPN and didn't think it was a problem to just leave the open line hanging. Now I wonder would they leave the catheter without a NC open? Who knows. As we all know there are all levels of nurses out there and sometimes no matter how much you instruct and teach they just don't seem to get it or they get busy and proper technique is overlooked. As far as home infusion goes I can see patients disconnecting infusions and forgetting to clamp prior to connecting a new bag. That does put them at an increased risk of not only infection but bleeds and air embolism. On another note I've been doing home infusion for over 25 years and the standard has always been to change NC weekly or with lab draws if they are done more frequently. I was on TPN for over a year and by NC was changed weekly with absolutely no issues.
It is my opinion that the very presence of the NC in a continuous infusion line makes if far too easy for nurses to disconnect the infusion without even thinking about it. This sets up bad practice. Not allowing the use of the NC in a continuous line, along with education and monitoring of their practice, will correct this issue. TPN should never be stopped for any reason. It violates the prescribers order and puts the patient at risk for blood glucose issues. the same could happen with other infusions as well. Lynn
I think a large part of the problem isn't whether or not to use NC (although I'm still 100% in favor of them) but nuirsing education. It's easy for those of us with lots of experience in infusion to set policies/procedures and care for infusion pts. The problem is there is very little if even any instruction in nursing schools throughout the country and therefore there is a dependence on preceptors on the floors to do the teaching. And a lot of times they don't have the infusion background either to teach correctly. I guarantee you 99% of in-patient nurses have no idea of blood glucose issues in stopping TPN-and I'm not even sure physicians are either. And as a f/u there was a MD order to d/c my TPN to allow me to get up to shower and as a confession I have d/c myself at home early due to various reasons without any issues-either in-patient or at home. I understand the theory behind rebound hypoglycemia but how often does it really happen and how big of a risk is it? I'm sure a lot of home patients do the same thing and we never hear of any issues. And before anyone gets all excited about the idea I can tell you from a personal experience of being on TPN for over a year (and also IV abt. and hydration) how much empathy I now have with any home infuson pt. Your entire life revolves around your therapy and you do make shortcuts at times.. Hopefully not in infection control but delaying dosage times, d/cing TPN early, etc It's easy for all of us to express how important it is for pts to follow set guidelines but being able to put myself in their shoes I can better understand their frustrations. So as they say "until you walk a mile in my shoes....". And I realize this has gotten way off subject-just a personal soapbox.
Debbie I can appreciate your comments about nurses lack of knowledge. But they are still held accountable for the outcome of their decisions. So lack of knowledge is not an acceptable defense for poor judgment or bad practice. This is one of many issues that is not yet answered by research. I do think that patients in home care would need to have the NC on the catheter hub even for cyclic TPN. We know that all NCs are a known source of organisms that lead to BSI. They serve no useful purpose for continuous infusions in hopsitalized patients and therefore, that risk can be eliminated in my opinion. Lynn
By "cap" are you talking about a needleless connector? Is this for continuous PN infusion in the hospital or for cyclic PN in the home? Lynn
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
I am refering to the needleless connector; we wish to know the "best practice" when hanging TPN in the hospital. We do change the tubing with each bag.
In my opinion, best practice is to totally eliminate the needleless connector for ALL continuous infusions including PN. These devices were designed for intermittent infusion and not intended for use in a continous infusion set. I would connect the luer lock set directly to the catheter hub, which is what was done prior to these devices being introduced. There is no research to support their use in a continous infusion of any kind. they are a known source of contamination leading to CRBSI. One reason I have been given is that the presence of a connector prevents opening the catheter lumen when changing the IV set. CDC states that the connector should be changed at the same interval as the IV set, so you still have to open the lumen. So there is no benefit to having these connectors inline for any continuous infusion. In fact, I also think that foster bad practices by allowing the nurse to interrupt the infusion for patient activity such as ambulation, etc. They give no thought to what is in the infusion, how long it will be disconnected, how to manage the disconnected set, and how to correctly ensure it is reconnected. This is done without policies and procedures and I think it is dangerous practice. Lynn
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
This makes sense Lynn. However, on more than one occasion I have been called out to a facility because the nurse had removed the needleless connector and connected the IV tubing directly into the PICC hub, only to find they (and myself) were unable to remove the tubing. It seems to get stuck. On one occasion, I used every technique I could think of....I eventually resorted to an over the catheter exchange.
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Any connection to the catheter hub can become permanently stuck to the female catheter hub. For details, go to the post on our new Blog
The Stuck Needleless Connector - Now What To Do? - Lynn Hadaway Associates, Inc.
Lynn
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
Although I could see a case for not useing a needleless connector on an inpatient with a continuous infusion in a closely monitored setting (ICU or MAYBE stepdown) I would caution against it in any other setting inpatient or outpatient. The needleless connector does serve a purpose. If the infusion is stopped for any reason, accidentially or purposefully, or the infusion tubing becomes disconnected from the hub of the catheter for any reason, intenionally or accidentially, the needleless connector protects that hub from contamination and ingress of germs, and also prefents the patient from bleeding through the catheter if the catheter is not clamped when the separation occurs. Not every patient is A and O x 3 with the ability to clamp the line in case of a problem.
The CDC Guidelines do not state to NOT use a needleless connector in any instance, and state the connector should be changed with the tubing, every 24 hours.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
I interpret the CDC guidelines in a totally different manner. There is evidence that changing the NC more frequently than 72 hours increases the risk of contamination and infection.
Also, why would a luer locked IV administration set connected direcly to the catheter hub have any greater risk of accidental or purposeful disconnection than a needleless connector with the IV set attached to the NC? Why would 2 luer-locked connections be better than 1? That makes no sense to me, especially since there is absolutely NO evidence to support the use of an NC within the infusion system for a continuous infusion. The new SHEA Compendium CLABSI chapter points out this lack of evidnece for their use in a continuous system. These were designed for intermittent connection and it is my opinion that is how they should be used. Lynn
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
I agree with Chris on this point. I think it's a huge risk for home infusion patients to not have NC on their lines. And as a point for in-patient use, as a pt myself who has received TPN both in-patient and out-patient I think it's also a risk for in-patient use. Lines are disconnected in-patient for various reasons such as allowing pts to shower/bathe and even for transportation. Now you can say that nurses should be taught and it should not be an issue in-patient but I can tell you from experience it is. I was a patient in a Level 1 trauma center and frequently had to correct floor nurses who would disconnect by TPN and didn't think it was a problem to just leave the open line hanging. Now I wonder would they leave the catheter without a NC open? Who knows. As we all know there are all levels of nurses out there and sometimes no matter how much you instruct and teach they just don't seem to get it or they get busy and proper technique is overlooked. As far as home infusion goes I can see patients disconnecting infusions and forgetting to clamp prior to connecting a new bag. That does put them at an increased risk of not only infection but bleeds and air embolism. On another note I've been doing home infusion for over 25 years and the standard has always been to change NC weekly or with lab draws if they are done more frequently. I was on TPN for over a year and by NC was changed weekly with absolutely no issues.
It is my opinion that the very presence of the NC in a continuous infusion line makes if far too easy for nurses to disconnect the infusion without even thinking about it. This sets up bad practice. Not allowing the use of the NC in a continuous line, along with education and monitoring of their practice, will correct this issue. TPN should never be stopped for any reason. It violates the prescribers order and puts the patient at risk for blood glucose issues. the same could happen with other infusions as well. Lynn
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
I think a large part of the problem isn't whether or not to use NC (although I'm still 100% in favor of them) but nuirsing education. It's easy for those of us with lots of experience in infusion to set policies/procedures and care for infusion pts. The problem is there is very little if even any instruction in nursing schools throughout the country and therefore there is a dependence on preceptors on the floors to do the teaching. And a lot of times they don't have the infusion background either to teach correctly. I guarantee you 99% of in-patient nurses have no idea of blood glucose issues in stopping TPN-and I'm not even sure physicians are either. And as a f/u there was a MD order to d/c my TPN to allow me to get up to shower and as a confession I have d/c myself at home early due to various reasons without any issues-either in-patient or at home. I understand the theory behind rebound hypoglycemia but how often does it really happen and how big of a risk is it? I'm sure a lot of home patients do the same thing and we never hear of any issues. And before anyone gets all excited about the idea I can tell you from a personal experience of being on TPN for over a year (and also IV abt. and hydration) how much empathy I now have with any home infuson pt. Your entire life revolves around your therapy and you do make shortcuts at times.. Hopefully not in infection control but delaying dosage times, d/cing TPN early, etc It's easy for all of us to express how important it is for pts to follow set guidelines but being able to put myself in their shoes I can better understand their frustrations. So as they say "until you walk a mile in my shoes....". And I realize this has gotten way off subject-just a personal soapbox.
Debbie I can appreciate your comments about nurses lack of knowledge. But they are still held accountable for the outcome of their decisions. So lack of knowledge is not an acceptable defense for poor judgment or bad practice. This is one of many issues that is not yet answered by research. I do think that patients in home care would need to have the NC on the catheter hub even for cyclic TPN. We know that all NCs are a known source of organisms that lead to BSI. They serve no useful purpose for continuous infusions in hopsitalized patients and therefore, that risk can be eliminated in my opinion. Lynn
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