Infection Control Today

MAY 2019

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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" To be most efective, institutions must ofer a variety of educational opportunities on diferent platforms (e.g. computer-based as well as in-person, hands-on training) to reach and engage everyone. 20 ICT May 2019 Infusion Nurses Standards of Practice recommend the use of engineered stabilization devices for better outcomes with all types of VADs. 5 The move toward a "clinically indicated" PIV catheter replacement strategy has brought even more attention to the importance of securement. Until recently, PIV catheters were replaced every 72 to 96 hours. However, based on numerous randomized trials, the Infusion Nurses Standards of Practice and the Centers for Disease Control and Prevention (CDC) now support the replacement of well-functioning catheters only when clinically indicated. 5,10-11 This shift has extended catheter dwell times, with many institutions leaving catheters in place for a week or more. As a result, there is greater focus on the need for more consistent securement and dressing practices. Step 2: Standardize Policies and Procedures While securement devices can certainly help, their use does not always prevent dislodgement. This is because of lack of standardization in practice usage, application, assessment and management of catheter securement and dressings. In any given institution, there is a great deal of variety in IV insertion and securement methods, as well as management of the tubing during the course a patient's treatment. For instance, patients are often disconnected from continuous infusions to allow for easier bathroom access. The disconnection process is not always done correctly, or even in an aseptic manner. This lack of standardization can lead to dislodgement and even other complications, such as infection. A key practice for ensuring catheter safety is for institutions to adopt a set of policies and procedures, including a standardized approach for the insertion and securement of all types of catheters. The approach should also include a clear process for disconnecting patients from their IVs in a way that covers sterile connections and maintains infection prevention principles. To reduce accidental dislodgement, there needs to be a consistent process, including education, in which every clinician within the facility is trained to insert, secure and manage catheters in the same way. Step 3: Technologies to Prevent Dislodgement Unfortunately, proper securement and standardized policies cannot address the one variable over which clinicians have the least control: patients themselves. Based on the clinical survey results, patient behavior accounts for two of the top three causes of dislodgement. Catheters that are correctly secured can nonetheless become dislodged when greater forces are exerted upon the catheter than the securement method was designed to withstand. These forces can be intentional or accidental. They can result from patients rolling over in bed or catching their lines on bed rails, transfers of patients to/from different beds, fdgeting pediatric patients, or disoriented patients pulling out lines. A new group of technologies, known as set protection devices, has been specifcally created to address this type of dislodgement. Using a safety release valve embedded in the tubing, the technology is designed to allow for a disconnection of the tubing when undue pressure or pull is placed on it. The safety release valve breaks away and seals off both sides of the tubing. This technology shuts off medication fow and preserves the catheter, while also allowing both the catheter and tubing to be protected in an aseptic manner. By preserving the entire IV set, this technology acts as a safeguard against patient or staff accidental dislodgements. While not yet commercially available, set protection devices may eventually offer hospitals and their patients a way to help prevent dislodgement and its potentially serious consequences. Step 4: The Importance of (Re)Education Perhaps the most crucial best practice involves education and training on the frequency and impact of dislodgement, and the steps that can be taken to minimize the risk. Effective education will raise awareness about the incidence of dislodgement, as well as ensure proper securement techniques are employed, policies and procedures are followed, and sterile supplies and technologies are used correctly. Education must also emphasize consistent practices that follow the institution's policies for insertion, securement and management of IV catheters. The importance of education cannot be overstated, as it ties all other practices together. In addition, education must be continuous and ongoing to remain effective. This not only accounts for the staff turnover that is inevitable in any institution, but also because infection prevention research shows the effects of education are temporary. 12-14 Typically, practices begin to degrade after a period of two to three months post-education, and outcomes suffer as a result. 14 Education must be done repeatedly to maintain good outcomes. To be most effective, institutions must offer a variety of educational opportunities on different platforms (e.g. computer-based as well as in-person, hands-on training) to reach and engage everyone. Looking Ahead: Better Auditing, More Research Clinicians need answers to direct best practices. Effective auditing and documentation will be the foundation of better vascular access device care in the future, as it will increase awareness and identify causes that lead to dislodgement. Monitoring complications and causes for catheter failure are necessary for any improvement in outcomes. There is a lack of high-level research establishing methods to protect patients and guide management of VAD sites. The Alliance for Vascular Access Teaching and Research (AVATAR) has begun to bridge this gap with the frst IV securement and dressing research in over 20 years. 6,15-17 However, we must focus greater research attention on dislodgement in terms of frequency, causes and impact on safety to continually improve clinical outcomes, reduce healthcare costs, and — most importantly — protect our patients. Nancy Moureau, RN, PhD, CRNI, CPUI, VA-BC, is an internationally recognized expert and speaker in the feld of peripherally inserted central catheters and vascular access practice. As the owner and CEO of PICC Excellence, Moureau creates online educational programs and works with companies to provide education to clinicians. She can be reached at

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