Studies show there is a need for clear recommendations and practices that prevent transmission of contaminants through NC [68, 90]. Various studies provide statements regarding conformity or lack of conformity concerning disinfection practices, attributing noncompliance to a lack of universal protocols, excessive workloads (e.g., when clinicians become busy, they are less likely to comply), or just forgetting to bring alcohol wipes to the bedside [54, 64, 72, 8993, 188]. (30) D. Warren, J. Zack, and J. Mayfield. Research may also validate the substantive effect of alcoholic chlorhexidine on NC and its continued antimicrobial activity on these surfaces, potentially establishing a reduced cleaning frequency or duration for NC. While policies for disinfection of access devices are a first step, methods to validate actual practice and patient safety must be integrated into hospital culture. Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review, PICC Excellence, Inc., Online Education, Hartwell, GA 30643, USA, Greenville Hospital System, Greenville, SC 29605, USA, Alliance for Vascular Access Teaching and Research (AVATAR group) Griffith University, Nathan, Brisbane, QLD 4111, Australia, Royal Brisbane & Womens Hospital, Brisbane, QLD 4029, Australia. Breaks in aseptic technique, from failure to disinfect, result in contamination and subsequent biofilm formation within NC and catheters increasing the potential for infection of central and peripheral catheters.

Results. disinfection agents used on intravascular device surfaces including studies and reviews of NC and infection prevention. curos disinfecting needleless fsa BEME Guide No. The Smith study on behavioral intention indicated a negative correlation between performing optimal disinfection with increasing age of clinicians and more years of experience [91]. Of note the Pittiruti study resulted in reductions of CLABSIs in the port protector/disinfection cap group and the control group, with improvements attributed to both the disinfection caps and educational efforts. Passive disinfection through hub protectors/disinfection caps have differing designs and colors, leading to easy recognition and validation of compliance with usage. Research of Macias and associates with 2% chlorhexidine in 70% isopropyl alcohol on skin proved an added substantive effect, even against freshly introduced organisms, for up to 24 hours, establishing this agent as a superior disinfecting agent when longer action is needed, in comparison with single agents of 70% isopropyl alcohol, 10% povidone iodine and 10% sodium hypochlorite [172]. National Health and Medical Research Council, NHMRC additional levels of evidence and grades for recommendations for developers of guidelines, Commonwealth of Australia, 2009, J. G. DeVries and G. C. Berlet, Understanding levels of evidence for scientific communication,, P. Pronovost, D. Needham, S. Berenholtz et al., An intervention to decrease catheter-related bloodstream infections in the ICU: Keystone Project,, I. S. Jeong, S. M. Park, J. M. Lee, J. Y. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. (15) W. Jarvis, C. Murphy, K. Hall et al.. (16) N. Khalidi, D. S. Sovacevich, L. F. Papke-ODonnell, and I. Btaiche. A BEME systematic review: BEME Guide No. (9) J. M. Costello, D. F. Morrow et al., (10) ECRI Institute, Evaluation: needleless connectors,. JCM MED223 Chemin de Bellevue, With the changes to the access point using direct luer connection through the NC, the intuitive sense to disinfect the surface prior to access is lost; many clinicians fail to realize the consequences of this breech in aseptic technique [46]. 15,, M. G. Cherry, J. M. Brown, G. S. Bethell, T. Neal, and N. J. Shaw, Features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a hospital care setting. NC used as a closed system must be weighed with consideration for potential negative factors of design features, poor aseptic practices, and lack of disinfection that all contribute to risk of infection [2, 121, 122]. sources of contamination through intravascular devices.

Criteria checklist for inclusion was any NC disinfection publications and abstracts that fit subcategories for disinfection, hub contamination/infection prevention, education/compliance, surveys, and guidelines/recommendations for disinfection. NC are used on virtually all intravascular devices in the USA; they provide an easy access point for syringe or tubing attachment and have now become the central access point for all connections. Numerous studies have demonstrated consistent clinical effectiveness of 70% alcohol caps alone in studies and abstracts graded C or D [18, 26, 27, 31, 33, 41, 43, 178, 189, 191194]. (3) J. D. Brown, H. A. Moss, and T. S. Elliott. As a progressive CLABSI intervention Posa at St. Joseph Mercy Health System implemented an insertion bundle, chlorhexidine bathing, a maintenance bundle, chlorhexidine dressing for central catheters, and educational programs, however it was not until implementing the 70% alcohol disinfection cap that their rates of CLABSI fell to zero and remained from 2011 to the end of 2012 The disinfection cap placed on all access ports eliminates human factor issues requiring clinicians to remember to carry the necessary disinfection supplies to the bedside or even to remember to perform the act of disinfection before each access [187]. This report is based on an electronic systematic literature search and review of published materials from Pubmed, Medline, Scopus, Ovid, jStor, CINAHL, Cochrane, Athens, and ScienceDirect by cross-referencing these key terms for years 1977December 2014. In Wright et al.s study at NorthShore University HealthSystem, a four University Hospital system, the intervention with 70% alcohol disinfection caps reported CLABSI rates declining from 1.42/1000 catheter days (16/11,540) to 0.69 (13/18,972) with a 95% confidence interval, based on 799 enrolled patients, representing a statistically significant decrease [26]. In actual practice disinfection prior to access is expected, while cleansing after each access is rarely done. Included studies consisted of 140 publications dealing with disinfection/catheter hub/NC contamination with 34 abstracts/posters. Studies to date have a risk of unintentional bias due to the lack of randomization and control groups/strategies, in addition to small sample sizes and retrospective study designs. In a study by Lee the disinfection compliance by clinicians prior to NC access was measured at only 10% [115]. Clearly hub contamination is a causative element in catheter related infections and one that demonstrates the necessity for effective hub disinfection prior to access [110, 113, 127, 133, 144, 149]. Thorough disinfection decreases the incidence rate of CRBSI (Catheter-Related Bloodstream Infection). With NC, these questions arise: is disinfection always performed prior to access? (5) M. Cole and K. Kennedy, Grady health system: decreasing central line associated blood stream infections (CLABSI) in adult ICUs through teamwork and ownership,, (6) H. Contreras, Use of disinfection cap/flush syringe combination to address bloodstream infection and related issues,, (7) B. Danielson, S. Williamson, G. Kaur et al., Decreasing the incidence of central line-associated blood stream infections using alcohol-impregnated port protectors (AIPPS) in a neonatal intensive care unit,, (8) M. Davis, Forcing the function: implementation and evaluation of an IV port protector to decrease CLABSI,, (9) R. Dawson and N. Moureau, Implementing new joint commission requirements using revised protocol to disinfect intravenous access ports/needleless connectors,, (10) M. DeVries, P. Mancos, and M. Valentine, Improving catheter cleaning and maintenance in central and peripheral lines,. needleless connectors iv cap positive central needless displacement caps catheter device devices lines story bsi syringe cvl infection fda Recommendations from both the Centers for Disease Control and the Infusion Nurses Society state clinician should minimize contamination risk by disinfection the access ports of the add-on device using friction with an appropriate disinfectant (70% alcohol, chlorhexidine, povidone iodine, and iodophors) prior to any access [8, 11, 24, 167, 168]. Kaler performed laboratory testing on contaminated NC with a small sample using 70% alcohol and alcoholic chlorhexidine and found both to be effective for hub disinfection [181]. (21) N. Moureau and R. Dawson, Passive disinfection product effectiveness study, AVA Annual Scientific Meeting, Poster Presentation, National Harbor, M.d., USA, September 2426, 2010. needleless prn Adequate cleaning or need for additional cleaning of the septal access site may be based on the specific design features of the individual NC [2, 4, 5, 7, 70, 111, 129, 153, 159161].

As demonstrated by multiple studies, infections are drastically lower or eliminated by disinfecting or covering the access hub with an antimicrobial cap [14, 1620, 113, 127, 144146]. NC have gaps of differing widths between the septal seal and the housing which may allow ingress of microorganisms [7, 23, 99, 143].

(30) M. B. Salzman, H. D. Isenberg et al.. (34) A. Sitges-Serra, J. Linares, and J. Garau. 22,, N. Arora, K. Patel, C. A. Engell, and J. Any intravascular access point with a surface open to the environment requires disinfection prior to use, as it acts as the immediate portal of entry for intraluminal contaminants [23, 99, 113, 127, 133, 144, 150152].

2015, Article ID 796762, 20 pages, 2015. https://doi.org/10.1155/2015/796762, 1PICC Excellence, Inc., Online Education, Hartwell, GA 30643, USA, 2Greenville Hospital System, Greenville, SC 29605, USA, 3Alliance for Vascular Access Teaching and Research (AVATAR group) Griffith University, Nathan, Brisbane, QLD 4111, Australia, 4Royal Brisbane & Womens Hospital, Brisbane, QLD 4029, Australia. However, despite the successes of the insertion bundle, full compliance more than seven years later is still lacking, with reported compliance rates at one institution ranging from 0.0% at the beginning of the intervention to 37.1% (139/375), according to the Jeong study, with similar results in other institutions [65, 66, 106, 107]. infection, infection prevention, catheter related infections, CLABSI, bloodstream infections, bacteremia, sepsis, and cross-infection. The optimal technique or disinfection time has not been identified, although scrubbing with 70% alcohol for 560 seconds is recommended. There were no identified formal published systematic reviews of the effectiveness of NC disinfection practices, indicating a knowledge gap in this area. In an evaluation of 5877 physicians, nurses and technicians, Jardim et al. included 472 patients and 3005 catheter days and showed a decrease in overall CLABSIs from 2.3 to 0.3/1000 catheter days and a PICC CLABSI reduction from 2.3 to 0, a statistically significant change, with an 85.2% compliance rate [31]. 139, no. B. Reaves, and R. I. Shorr, Risk of venous thromboembolism in hospitalized patients with peripherally inserted central catheters,, I. I. Raad, M. Luna, S.-A. needleless medneteurope NC disinfection is an excellent subject for efficacy studies utilizing comparative research for various disinfection approaches identifying relative reductions in patient infection risk. Is disinfection performed in an effective manner? The greatest risk for contamination of the catheter after insertion is the access hub with 3345% (402/900) contaminated in normal patient use [6, 15, 128132]. Song, and S. J. Lee. Selected papers were subjected to full-text assessment. (40) C. Stango, D. Runyon, J. Stern, I. Macri, and M. Vacca. Another alcoholic hub protector study by Sweet et al. intravenous connector, NC, luer activated device, and mechanical valve. When the cleansing cap was used on stopcocks Holroyd found contamination and increased CFU. Needleless connectors (NC) are used on virtually all intravascular devices, providing an easy access point for infusion connection. Just one omission of scrubbing the hub prior to access permits bacterial entry, attachment and biofilm formation that allow the bacteria to strengthen prior to release into the bloodstream. Rice, Universal intravenous access cleaning device fails to sterilize stopcocks,, D. G. Maki, In vitro studies of a novel antimicrobial luer-activated needleless connector for prevention of catheter-related bloodstream infection,, R. Orenstein, The benefits and limitations of needle protectors and needleless intravenous systems,, W. Jarvis, Needleless connectors and the improvement of patient and healthcare professional safety,, ECRI Institute, Evaluation: needleless connectors,, L. Hadaway, Hub disinfection and its impact on Catheter-related infections,, C. Chernecky, D. Macklin, L. Casella, and E. Jarvis, Caring for patients with cancer through nursing knowledge of IV connectors,, C. D. Salgado, L. Chinnes, T. H. Paczesny, and J. R. Cantey, Increased rate of catheter-related bloodstream infection associated with use of a needleless mechanical valve device at a long-term acute care hospital,, J. L. Lockman, E. S. Heitmiller, J. Because catheters provide an open conduit into the vasculature, a NC is attached, via luer threaded connection, to the integrated hub end of the catheter establishing a closed system. Moro reported hub colonization in only 3.5% (21/607), but found that this group was responsible for severe systemic infections more frequently [128]. While these products did eliminate the risk of accidental needle injury for the clinician, some needleless products raised new issues for the patient; namely, a noted increase in the occurrence of catheter associated bloodstream infections (CABSI) and central line associated bloodstream infections (CLABSI) [13]. (17) B. S. Nil-Weise, T. J. Daha, P. J. van den Broek. Infection prevention guidelines and recommendations. Primary areas of focus for disinfection of access sites are the point where the sterile syringe or tubing contacts the site, as in the top septum surface, and the threads or side surfaces [7, 143, 154]. Recommendations from the Centers for Disease Control [8], the Agency for Healthcare Research and Quality [9], the Society for Healthcare Epidemiology of America [10], and the Infusion Nurses Society [11, 118] state that NC should be consistently and thoroughly disinfected using mechanical friction with 70% alcohol, alcoholic chlorhexidine, or povidone iodine prior to each access of an intravascular device and listed in evidence as a Category 1A. Search results were evaluated by title, abstract, and content. Study considerations for passive disinfection coupled with prefilled flush syringes could demonstrate drastic reduction of hub contamination and intraluminal biofilm colonization, but ultimately patient infection outcomes are needed. Randomized controlled trials are needed to identify if risk reduction differs with the type of antiseptic, for example, 70% alcohol versus 70% alcohol and chlorhexidine, or with differing concentrations of chlorhexidine in their efficacy for disinfection NC. (32) D. K. Warren, D. S. Yokoe, M. W. Climo et al.. (33) D. K. Warren, J. E. Zack, M. J. Cox, M. M. Cohen, and V. J. Fraser. Julie Flynn performed grading of selected publications and contributed to second paper revision.

These studies found that bacteria identified on external hub surfaces were also present in biofilm sampled from random locations within the needless connector. This systematic review highlights the lack of available high quality research in this area that tests the cause and effect relationship between NC disinfection practices and patient infection outcomes. (35) W. Zingg, A. Imhof, M. Maggiorini et al., Recommendations for disinfecting practices, Use disinfection on surfaces of needleless connectors, stopcocks and other intravascular access ports immediately prior to any connection, infusion or aspiration with appropriate antiseptic agent (e.g., alcoholic chlorhexidine, povidone iodine, an iodophor, or 70% alcohol). (18) R. D. Lobo, A. S. Levin, L. M. Gomes et al.. (19) D. Macklin, C. Chernecky, K. Nugent, J. Waller. Measurement of compliance with hub disinfection is challenging, requiring direct observation of the action unless disinfection caps/ports are used on all NC hubs as a form of verification.

Split septum access devices continue to be recommended as a lower risk option for needleless connection; however, they have lost popularity because they require multiple parts and pieces for access and allow direct needle access through the septum/diaphragm leading many facilities to switch to luer access devices. Why disinfect? Colonization of catheter hubs and NC, with subsequent bacterial ingress into the catheter lumen, is considered the cause of 50% of postinsertion catheter-related infections [37].

Any puncture through the protective skin barrier creates a portal for bacteria to enter the body. Copyright 2015 Nancy L. Moureau and Julie Flynn.

126150, 2010. (26) C. M. Rickard, J. Webster, and E. G. Playford, (27) M. Ryder, G. Hamilton, M. Hamilton, and G. James, Bacterial transfer through needlefree connectors: comparison of nine different devices,. (24) I. Raad, M. Luna, S. Khalil, J. Costerton, C. Lam, and G. Bodey. Nancy L. Moureau is a speaker and educational consultant with 3M, Access Scientific, Analogic, Angiodynamics, Arrow/Teleflex, Baxter, Carefusion, Cook, Excelsior, Genentech, Hospira, Nexus, Vascular Pathways, and Vygon; chief executive officer of PICC Excellence, Inc., and clinician at Greenville Memorial Hospital.

Initially, needleless split septum access points used a blunt needle-looking type cannula. We use cookies to ensure that we give you the best experience on our website. Early concerns over needle safety for healthcare workers led to the creation of products that provide needle-free access. Disinfecting agents and devices literature. Part 2: patient controlled analgesia,, D. D. McMahon, Evaluating new technology to improve patient outcomes: a quality improvement approach,, S. Cicalini, F. Palmieri, and N. Petrosillo, Clinical review: new technologies for prevention of intravascular catheter-related infections,, S. T. Cookson, M. Ihrig, E. M. O'Mara et al., Increased bloodstream infection rates in surgical patients associated with variation from recommended use and care following implementation of a needleless device,, J. S. Soothill, K. Bravery, A. Ho, S. Macqueen, J. Collins, and P. Lock, A fall in bloodstream infections followed a change to 2% chlorhexidine in 70% isopropanol for catheter connection antisepsis: a pediatric single center before/after study on a hemopoietic stem cell transplant ward,, S. Sannoh, B. Clones, J. Munoz, M. Montecalvo, and B. Parvez, A multimodal approach to central venous catheter hub care can decrease catheter-related bloodstream infection,, J. S. Smith, G. Irwin, M. Viney et al., Optimal disinfection times for needleless intravenous connectors,, M. E. Rupp, S. Yu, T. Huerta et al., Adequate disinfection of a split-septum needleless intravascular connector with a 5-second alcohol scrub,, J. H. Macias, V. Arreguin, J. M. Munoz, J. In early studies by Sitges-Serra colonization of the catheter hub was considered the primary pathogenesis of catheter associated infection [15, 113]. (15) C. Leon, F. Alvarez-Lerma, S. Ruiz-Santana et al.. (18) J. L. Lockman, E. S. Heitmiller, J. Julie Flynn is a research doctorate candidate (April, 2015) with the Alliance for Vascular Access Teaching and Research, Griffith University, and active clinician at Royal Brisbane and Womens Hospital. Care and management of catheters takes up more than 99% of the dwell time of a catheter compared to the one hour or less for catheter insertion. Effectiveness of 70% alcohol disinfection is variable based on application techniques and characteristics of NC surface and design, leading some researchers to conclude that complete disinfection of microorganisms on some NC surfaces may not be achievable [12]. (36) M. Segura, F. Alvarez-Lerma, J. M. Tellado et al.. (37) S. Simmons, C. Bryson, and S. Porter. A. LaRosa, The effect of interdisciplinary team rounds on urinary catheter and central venous catheter days and rates of infection,, K. R. Herzer, L. Niessen, D. O. Constenla, W. J.

Broad MeSH search term disinfection and needleless connector combinations were used with additional keywords listed below:(i)disinfection, antiseptic, alcohol, chlorhexidine, and anti-infective agents,(ii)intravenous, intravascular, and vascular access,(iii)hub, catheter hub, scrub the hub,(iv)intravenous connector, NC, luer activated device, and mechanical valve,(v)aseptic practices, contamination, and compliance,(vi)education, staff education, and medical education,(vii)infection, infection prevention, catheter related infections, CLABSI, bloodstream infections, bacteremia, sepsis, and cross-infection,(viii)catheter maintenance and line care,(ix)insertion and bundle,(x)intravenous technology,(xi)catheter cap, access port, disinfecting cap, antimicrobial cap, hub protection cap, and port protector,(xii)Infection prevention guidelines and recommendations. Two additional studies gave conflicting results.

(41) M. A. The author wishes to thank Gigi Macher, Nancy League, and Charles Rushing, M.D., for their assistance in organizing, reviewing materials, and editing the paper and Griffith University, Samantha Keogh, and Claire Rickard for facilitating access to literature review and allocation of resources for grading of the studies. Intraluminal contamination and subsequent colonization become more prominent with longer dwell times [110, 147]. technology.

In the Menyhay prospective in vitro study, 20 (67%) of 30 NC disinfected with 70% alcohol resulted in transmission of contaminants (44225,000CFU) yet 60 tested with barrier caps (containing 2% chlorhexidine and 70% alcohol) showed only one (1.6%) with transmission of contaminants [19]. education, staff education, and medical education. The strength of this review is that it includes all relevant, currently available pieces of evidence; however there remains a high level of uncertainty in the estimates of effectiveness of various decontamination techniques, and these are highly likely to change with the publication of new studies in the literature.

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