disconnection of IV lines in Medical Imaging

[Lincoln Fowler]

Hi all

In trying to implement a no disconnection policy for our IV lines. I
have had some opposition from Medical Imaging:

“IV lines need to be disconnected only for a few reasons. … whilst the
patient was in the fluoroscopy machine as there is a risk of getting the
line caught in the equipment. For these types of procedures the table
rotates vertically and horizontally so that the patient can be standing
or lying down to assess the upper GI tract. Other occasions where we
need to disconnect the line is when there is no access for CT IV
contrast whilst the line is connected.” I believe the last point is that
they want to use the in use IV cannula so they disconnect it and attach
their device.

I am interested in what guidelines are in place in other organisations
to assist in situations like these.

Cheers

Lincoln Fowler

Infection Prevention Consultant

Bairnsdale Regional Health Service

http://www.brhs.com.au

Bairnsdale Regional Health Service is located on the traditional land of
the Gunaikurnai people.

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[Ryan, Lindy]

Dear Lincoln

I have attached NSW CEC PIVC guidelines. The development of this document was a very hotly debated & commented on (& still is).

Anyhow our NSW state guidelines recommend as per below

Guideline for PIVC Insertion and Post Insertion Care in Adult Patients
GUIDELINE
GL2013_013 Issue date: December-2013 Page 8 of 16

9.3.2 IV tubing sets should not be disconnected for routine care, but may be disconnected for transient, controlled disconnections such as changing IV infusions, removing a sling or sleeve, or access in Operating Theatres, Medical Imaging or Radiology Departments.

9.3.3 Except for transient controlled disconnections as above, if the IV giving set is disconnected, replace the entire IV tubing.

Hope this information useful

Regards

Lindy Ryan

Lindy Ryan

Infection prevention & Control Clinical Nurse Consultant (CNC) | Coffs Harbour Health Campus
Pacific Hwy Coffs Harbour NSW 2450
Tel (02) 6656 7770 | lindy.ryan@ncahs.health.nsw.gov.au
http://www.health.nsw.gov.au

Hi all
In trying to implement a no disconnection policy for our IV lines. I have had some opposition from Medical Imaging:
“IV lines need to be disconnected only for a few reasons. … whilst the patient was in the fluoroscopy machine as there is a risk of getting the line caught in the equipment. For these types of procedures the table rotates vertically and horizontally so that the patient can be standing or lying down to assess the upper GI tract. Other occasions where we need to disconnect the line is when there is no access for CT IV contrast whilst the line is connected.” I believe the last point is that they want to use the in use IV cannula so they disconnect it and attach their device.
I am interested in what guidelines are in place in other organisations to assist in situations like these.
Cheers

Lincoln Fowler
Infection Prevention Consultant

Bairnsdale Regional Health Service
http://www.brhs.com.au

Bairnsdale Regional Health Service is located on the traditional land of the Gunaikurnai people.

This communication is intended only to be read or used by the addressee. Information contained in this communication may be confidential information. If you are not the intended recipient, any use, interference with, distribution, disclosure or copying of this material is unauthorised and prohibited. The confidentiality attached to this communication is not waived or lost by reason of the mistaken delivery to you. If you have received this communication in error, please destroy it and send a reply message to the author.

MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.

Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.

Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au

To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.

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________________________________

This message is intended for the addressee(s) named and may contain confidential information. If you are not the intended recipient, please delete the message and any attachments and notify the sender. Views expressed in this message are those of the individual sender, and are not necessarily the views of NSW Health or any of its entities.

MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

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[Tim Spencer]

Hi Lindy and Lincoln,

It is interesting to ask what and who determines what a ‘transient
controlled disconnection’ is? The problem is that these disconnections are
performed by a large variety of clinicians (non-nursing colleagues also) who
do not always know or understand IV best practices.

I would definitely NOT recommend a disconnection just for removing a sleeve
or a sling at all – this is a high risk opportunity for contamination and is
an unnecessary disconnection. It takes the same time to feed the IV
administration set through the patients sleeve as it does to disconnect and
re-connect, less the infection/contamination risk.

The key point I would consider here is that if an IV administration set
disconnection is required (for whatever procedure), the hubs must be
correctly disinfected after the disconnection and before re-connection of
the original administration set.

The administration set luer connector also must be covered with a sterile
device (blunt cannula and cover) during the investigative procedure.

When reconnection occurs, then the needle free device should be
decontaminated with 70% IPA.

I have cut and pasted from the current INS Guidelines & CDC (2011) state in
regards to peripheral IV administration sets and disconnection;

26. ADD-ON DEVICES

Standard

26.1 The use of add-on devices shall be established in organizational
policies, procedures, and/or practice

guidelines and according to manufacturers’ directions for use.

26.2 The nurse shall be competent in the use of the add-on device and shall
be knowledgeable about the

risk of misconnection and potential disconnections.

26.3 All add-on devices shall be of luer-lock design to ensure a secure
junction.

Practice Criteria

A. Add-on devices may include, but are not limited to, stopcocks, single and
multi lumen extension sets,

manifold sets, extension loops, solid cannula caps, needleless systems,
in-line filters, and manual flow control

devices.1 (V)

B. All add-on devices should be compatible with the administration system to
prevent the risk of leaks,

disconnections, or misconnections.2,3 (V)

C. The nurse should be aware that the potential for contamination exists
with all add-on devices. In

an effort to decrease the risk of contamination, the number of manipulation
episodes, accidental

disconnections or misconnections, and costs, there should be limited use of
these devices.1 (V)

D. To determine the appropriate placement of the selected add-on device, the
nurse should trace the

administration set from the patient to the point of origin before attaching
the device.2,4,5 (IV)

E. The nurse should disinfect the ports of the add-on device using friction,
with an appropriate disinfectant

such as 70% alcohol before accessing. Specific guidelines directing the
appropriate technique,

disinfectant, or amount of time required to- clean devices prior to access
are unresolved. The

access port should be accessed only with sterile devices.6,7 (V)

F. The nurse should change the add-on device with the catheter, with each
administration set replacement,

or as defined by the organization, and whenever the integrity of the product
is compromised

or suspected of being compromised.1 (V)

G. The use of stopcocks is not recommended due to the increased risk of
infection. When a stopcock is

attached as an add-on device, the nurse should attach sterile caps to the
ports of the stopcock to

provide a closed system when not in use and access sites that will allow
cleaning prior to accessing.1 (V)

REFERENCES

1. Hadaway L. Infusion therapy equipment. In: Alexander M, Corrigan A,
Gorski L, Hankins J, Perucca R. eds. Infusion

Saunders/Elsevier; 2010:391-436.

2. The Joint Commission. Tubing misconnections: a persistent and potentially
deadly occurrence. Joint Commission Sentinel Event

Alert.
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_36.htm.
Accessed December 5, 2009.

3. US Food and Drug Administration. 2009 medical device safety calendar on
luer misconnections. http://www.fda.gov/medicaldevices/

Safety/AlertsandNotices/ucm134863.htm. Accessed July 8, 2009.

4. Institute for Safe Medication Practices (ISMP). Problems persist with
life-threatening tubing misconnections. Medication Safe

Alert! June 17, 2004.

5. American Nurses Association [position paper]. Safety Issues Related to
Tubing & Catheter Misconnections. http://www.nursingworld.org/

position/practice/tube.aspx. Accessed February 13, 2010.

6. Kaler W, Chinn R. Successful disinfection of needleless mechanical valve
access ports: a matter of time and friction. J Assoc

Vascular Access. 2007;12(3):140-142.

7. Marschall J, Mermel L, Classen D, et al. Compendium of strategies to
prevent central line-associated bloodstream infections in acute care

hospitals. Infect Control Hosp Epidemiol. 2008;29(S1):S22-S30.

43. ADMINISTRATION SET CHANGE

Standard

43.1 Administration set changes shall be performed routinely, based on
factors such as type of solution administered,

type of the infusion (continuous versus intermittent), immediately upon
suspected contamination, or when the

integrity of the product or system has been compromised.

43.2 The administration set shall be changed whenever the peripheral
catheter site is rotated or when a new

central vascular access device is placed.

43.3 Add-on devices used as part of the administration set, such as single
and multi lumen extension sets and filters,

shall be changed at the same time as the administration set.

43.4 The frequency of performing administration set changes and the system
used to promote adherence to

administration set change (eg, labeling/electronic) shall be established in
organizational policies, procedures,

and/or practice guidelines.

43.5 A vented administration set shall be used for solutions supplied in
glass or semi-rigid containers, and a nonvented

administration set shall be used for plastic fluid containers.

43.6 All administration sets shall be of luer-lock design to ensure a secure
junction.

Practice Criteria

I. General

A. The use of add-on devices for administration sets should be minimized as
each device is a potential

source of contamination, misuse, and disconnection; it is preferable to use
an administration set with

devices as an integral part of the set (see Standard 26, Add-on Devices).1
(V)

Practice Criteria

II. Primary and Secondary Continuous Infusions

A. Primary and secondary continuous administration sets used to administer
fluids other than lipid, blood,

or blood products should be changed no more frequently than every 96 hours.
There is strong evidence

that changing the administration sets more frequently does not decrease the
risk of infection.2-3 (I)

B. Extending the administration set change to every 7 days may be considered
when an anti-infective

central vascular access device (CVAD) is being used or if fluids that
enhance microbial growth

are not administered through the set.3,4 (II)

C. If a secondary administration set is detached from the primary
administration set, the secondary

administration set is considered a primary intermittent administration set
and should be changed

every 24 hours (see Practice Criteria III, Primary Intermittent Infusions).1
(V)

D. When compatibility of infusates is verified, use of secondary
administration sets that use back-priming

infusion methods are preferred due to reduced need for disconnecting
secondary intermittent

administration sets.1 (V)

Practice Criteria

III. Primary Intermittent Infusions

A. Primary intermittent administration sets should be changed every 24
hours. When an intermittent

infusion is repeatedly disconnected and reconnected for the infusion, there
is increased risk of contamination

at the catheter hub, needleless connector, and the male luer end of the
administration set, potentially

increasing risk for catheter-related bloodstream infection. There is an
absence of studies addressing administration

set changes for intermittent infusions. In a meta-analysis of 12 randomized,
controlled trials that supported

increasing the time interval for administration set changes to 96 hours, at
least 2 of the studies

excluded administration sets used for heparin locked catheters and in sets
disconnected for more

than 4 hours. In several others, exclusions were not stated.1,5 (V)

B. A new, sterile, compatible covering device should be aseptically attached
to the end of the administration

set after each intermittent use. The practice of attaching the exposed end
of the administration

set to a port on the same set (“looping”) should be avoided.1,5 (V)

The CDC 2011 Guidelines are also unresolved on this point of disconnection,
but strong on the decontamination process;

Replacement of Administration Sets

1. In patients not receiving blood, blood products or fat emulsions, replace
administration sets that are continuously used, including secondary sets and
add-on devices, no more frequently than at 96-hour intervals, [177] but at
least every 7 days [178-181]. Category IA

2. No recommendation can be made regarding the frequency for replacing
intermittently used administration sets. Unresolved issue

Needleless Intravascular Catheter Systems

1. Change the needleless components at least as frequently as the
administration set. There is no benefit to changing these more frequently
than every 72 hours. [39, 187-193]. Category II

2. Change needleless connectors no more frequently than every 72 hours or
according to manufacturers’ recommendations for the purpose of reducing
infection rates *187, 189, 192, 193]. Category II

3. Ensure that all components of the system are compatible to minimize leaks
and breaks in the system [194]. Category II

4. Minimize contamination risk by scrubbing the access port with an
appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70%
alcohol) and accessing the port only with sterile devices [189, 192,
194-196]. Category IA

5. Use a needleless system to access IV tubing. Category IC

The CDC document doesn’t really provide any concrete information on the set
change issue as it was unresolved (surprisingly), but provides Cat 1A
support for decontaminating devices.

If you need a copy, please let me know and I can provide one.

Regards,

Tim..

Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert, VA-BC.

Independent Vascular Access Consultant
President, Australian Vascular Access Society
Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine |
University of NSW

Director-at-Large, Vascular Access Certification Corporation (VACC)

Representative – WoCoVA Global Strategic Committee
M: +1 (623) 326 8889 (USA)

M: +61 (0)409 463 428 (AU)
E: tim.spencer68@icloud.com

“Be a yardstick of quality. Some people aren’t used to an environment where
excellence is expected.” – Steve Jobs

Of Ryan, Lindy

Dear Lincoln

I have attached NSW CEC PIVC guidelines. The development of this document
was a very hotly debated & commented on (& still is).

Anyhow our NSW state guidelines recommend as per below

Guideline for PIVC Insertion and Post Insertion Care in Adult Patients

GUIDELINE

GL2013_013 Issue date: December-2013 Page 8 of 16

9.3.2 IV tubing sets should not be disconnected for routine care, but may be
disconnected for transient, controlled disconnections such as changing IV
infusions, removing a sling or sleeve, or access in Operating Theatres,
Medical Imaging or Radiology Departments.

9.3.3 Except for transient controlled disconnections as above, if the IV
giving set is disconnected, replace the entire IV tubing.

Hope this information useful

Regards

Lindy Ryan

Lindy Ryan

Infection prevention & Control Clinical Nurse Consultant (CNC) | Coffs
Harbour Health Campus

Pacific Hwy Coffs Harbour NSW 2450
Tel (02) 6656 7770 | lindy.ryan@ncahs.health.nsw.gov.au

http://www.health.nsw.gov.au

Of Lincoln Fowler

Hi all

In trying to implement a no disconnection policy for our IV lines. I have
had some opposition from Medical Imaging:

“IV lines need to be disconnected only for a few reasons. . whilst the
patient was in the fluoroscopy machine as there is a risk of getting the
line caught in the equipment. For these types of procedures the table
rotates vertically and horizontally so that the patient can be standing or
lying down to assess the upper GI tract. Other occasions where we need to
disconnect the line is when there is no access for CT IV contrast whilst the
line is connected.” I believe the last point is that they want to use the in
use IV cannula so they disconnect it and attach their device.

I am interested in what guidelines are in place in other organisations to
assist in situations like these.

Cheers

Lincoln Fowler

Infection Prevention Consultant

Bairnsdale Regional Health Service

http://www.brhs.com.au

Bairnsdale Regional Health Service is located on the traditional land of the
Gunaikurnai people.

This communication is intended only to be read or used by the addressee.
Information contained in this communication may be confidential information.
If you are not the intended recipient, any use, interference with,
distribution, disclosure or copying of this material is unauthorised and
prohibited. The confidentiality attached to this communication is not waived
or lost by reason of the mistaken delivery to you. If you have received this
communication in error, please destroy it and send a reply message to the
author.

MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
NOT REPRESENT THE OPINION OF ACIPC.

The use of trade/product/commercial brand names through the list is
discouraged by ACIPC. If you wish to discuss specific reference to products
or services by brand or commercial names, please do this outside the list.

Archive of all messages are available at http://aicalist.org.au/archives –
registration and login required.

Replies to this message will be directed back to the list. To create a new
message send an email to aicalist@aicalist.org.au

To send a message to the list administrator send an email to
aicalist-request@aicalist.org.au .

You can unsubscribe from this list be sending ‘signoff aicalist’ (without
the quotes) to listserv@aicalist.org.au

_____

This message is intended for the addressee(s) named and may contain
confidential information. If you are not the intended recipient, please
delete the message and any attachments and notify the sender. Views
expressed in this message are those of the individual sender, and are not
necessarily the views of NSW Health or any of its entities.

MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
NOT REPRESENT THE OPINION OF ACIPC.

The use of trade/product/commercial brand names through the list is
discouraged by ACIPC. If you wish to discuss specific reference to products
or services by brand or commercial names, please do this outside the list.

Archive of all messages are available at http://aicalist.org.au/archives –
registration and login required.

Replies to this message will be directed back to the list. To create a new
message send an email to aicalist@aicalist.org.au

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aicalist-request@aicalist.org.au .

You can unsubscribe from this list be sending ‘signoff aicalist’ (without
the quotes) to listserv@aicalist.org.au

MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.

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