I agree that we definitely do not have all the answers and need a
lot more data before any conclusions can be drawn. We do need to make
our colleagues aware of these issues though. As you might have guessed
I have some personal ideas about the causes of this problem.
I strongly believe that this is caused by many factors involving
the nurse and the valve and the patient. The nurses performance can be
broken down into 2 categories - a knowledge deficit and a performance
deficit. Last summer when my father had returned from surgery with a
complication, the nurse came in to inject a dose of IV steroid without
wiping the luer connection. I stopped her and explained my concern.
Her response was, "Yes, I hope you knew that I knew to do that."
So she was knowledgeable but was not performing appropriately.
Then there are those others that do not recognize the need to
wipe a luer connector. Think about what has been (or has not been
taught to these nurses). There has always been a heavy emphasis on
wiping a surface when we are injecting anything - we clean the skin
before IM or SC or IV injections along with the split septum before a
blunt cannula is injected. But when we are connecting luer locking
tubing together we do not need to clean that because the sterile ends
are protected with a cover. It is hard for me to imagine that a nurse
can not see that the luer connection of a mechanical valve needs to be
cleaned before use, but apparently this is a bigger problem than we
thought.
Then there are the other issues as Tim described with device
design and patient immune status. Also there is the issue of what the
various sales reps are teaching the nurses. Are any of them telling
nurses that a mechanical valve does not need to be cleaned? I
certainly hope not, but this could also be part of the problem. What
are they saying about the frequency of changing the valves? Do they
understand the issues of biofilm that grows in all needleless
connectors?
So we have a long way to go with learning the answers to this
issue. Lynn
At 9:35 AM -0800 1/17/06, Bev and Tim Royer wrote:
My data suggests that it is probably a multitude of different factors. I am able to track central lines in the facility and into the outpatient arena that I am working in.
On the topic of infection rates - if it was just the valves causing the growing infection rates then you should a pretty even spread catheter related blood stream infections throughout the facility. The same valve is used in all the different areas. One med/surg unit continually has a higher infection rate including the immune compromised area of our cancer care unit. Our outpatient population has a low infection rate. Other med/surg units continually have low infection rates including the ICUs. If the valve was the sole cause of the increasing infection rates through out the country then there should be comparable infection rate throughout. This has lead me to believe that it is NOT just the valves.
Factors, in my mind, that have influence on rates
Compliance of staff with cleaning and maintaining their central lines
Valve construction
Surface area within the valve
The outside surface of the valve
Flow path
Is the valve clear so you can see blood in the valve
How valves are cleaned and accessed
How often staff flush valves and the amount flush used
Dedicated IV / PICC Team that maintains the central lines
Patient education and follow-up
Staff education
I am sure there are other factors involved
We do need more evidence.
Timothy Royer, BSN, CRNI
Nurse Manager / Vascular Access / Diagnostic Service
VA Puget Sound Health Care System
Seattle / Tacoma, WA
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Chris Cavanaugh
Sent: Tuesday, January 17, 2006 3:37 AM
To: [EMAIL PROTECTED]; [EMAIL PROTECTED]
Cc: [EMAIL PROTECTED]
Subject: RE: Needless Connectors & CRBSI
Sorry, just have to jump in on this one, my impressions from what I heard at AVA was that there IS evidence. Facilities that used mechanical valve adaptors saw their CRBSI go up, and returned to lower numbers after they returned to split septum systems. That was the jist of both Dr. Maki and Jarvis's statements. The manufactures like to spread the 'clinician care' angle, but that does not seem possible when it is so many facilities having the same problem. The reality is that germs get stuck in the plunger of some devices, probably not all. And, when we flush these devices the germs get flushed into the catheter. This does not happen with a split septum system. There is an easy way to tell if your particular brand of mechanical valve is guilty of this---Bug Glo. Drop some Bug GLO on your valve, swab vigorously with alcohol, assuming best practice, then look at your valve. Does it still show bug glo or did you get it all off? No manufacture will allow data to be published stating their valve causes infections, and this is a lot faster, and safer than a study. Of course, if you have not seen CRBSIs go up in your institution, it may not be a problem for you-you may be using one of the good devices. If so, THAT should be published. Good luck to all----this is a surprising conclusion. We went needleless for safety, then to mechanical valves for either positive pressure (a myth) to prevent occlusions or for luer lock access, never thinking it would lead to another problem, a much more dangerous problem like increased CRBSIs. I think what this does show to all of us is that the latest and greatest technology may not be..
Chris Cavanaugh, CRNI
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of [EMAIL PROTECTED]
Sent: Monday, January 16, 2006 11:04 PM
To: [EMAIL PROTECTED]
Cc: [EMAIL PROTECTED]
Subject: Re: Needless Connectors & CRBSI
Well Peter you hit the question exactly. Drs Maki and Jarvis did not mention a specific brand. The word from valve manufacturers seems to be blaming weaknesses in the fluid path seal that allow liquid contaminates in. I heard practioners talking about poor staff education and/or compliance with swabbing as a possible cause.
But truly we don't know that there is a problem. There was no data given as to type of valve or how it was used or how staff was educated. There was no data about a trailing a different valve to see if there was a difference. and no mention was made as to the reeducation of staff and a trail to follow that.
So I feel we have many more questions to answer before we start tossing our valves in the can. But certainly it is interesting and worthy of note. I hope that everyone will begin taking a close look at the numbers in their facilities. Perhaps a few quick small trials to see if any trends emerge.
Tony
In a message dated 1/15/2006 8:14:56 P.M. Central Standard Time, [EMAIL PROTECTED] writes:
Thank you Tony for keeping us all up to date with the conference!! A question though is burning in my mind. I don't recall, from the disscussion we had on the list this spring/summer, about a brand specific needless connector being responsible for for the increase in CRBSI. So could you please tell us which connector(s) are in question? What is the reason that belies a particular valve design, that makes it prone to causing CRBSI?Peter Marino RN BSN----- Original Message -----From: [EMAIL PROTECTED]Date: Sunday, January 15, 2006 12:06 amSubject: AVA conference, DAY 3"The topic was needleless connectors. They discussed the qualities of a needleless device that would contribute to maintaining a safe fluid pathway. The premise is that the association of increased catheter related infections with valves is likely a brand specific problem and not a wholesale problem of the device category as Drs Maki and Jarvis's data might have led one to believe."> Tony West, RN, CRNI
> Healix, Inc.
> Email: [EMAIL PROTECTED] or [EMAIL PROTECTED]
> SMS: [EMAIL PROTECTED]
> Cell: 214-674-4848
--
Lynn Hadaway, M.Ed., RNC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
http://www.hadawayassociates.com
office 770-358-7861
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
http://www.hadawayassociates.com
office 770-358-7861
