RE cleaning of inner cannulas of tracheostomy tubes.

[Anonymous]

Dear All,
The Intensive Care and Coordination monitoring unit (ICCMU) is working on a tracheostomy guideline. The recommendations around cleaning of the inner cannulas are as in the table below:

Recommendations

Grade of Recommendation

1.

The inner cannula must be checked for patency, cleaned and replaced 2-4hourly. More frequent checks will depend on the volume and viscosity of secretions.

Consensus

2.

The inner cannula should be cleaned and dried according to manufacturer’s guidelines and stored in a clean dry container.

Consensus

3.

Under most circumstances the inner cannula can be cleaned with sterile water with a tracheostomy cleaning brush or a pipe cleaner (with the end turned over). Where secretions are tenacious, alternative solutions can be used; however, the tube should not be soaked for more than 15 minutes.

Consensus

4.

This procedure is a clean procedure which requires hand hygiene before and after donning appropriate PPE e.g.; gloves, apron, full-face visor.

Consensus

5.

It is inappropriate to clean or rinse the inner cannula at hand basins used for hand washing because of the risk of contaminating the basin with organisms or contamination of the inner cannula.

Consensus

6.

When placing a clean inner cannula into a TT tube it should be rinsed with sterile water immediately prior to insertion.

Consensus

Consensus means that the guideline group & external validation panel agreed on this recommendation (using a likert scale 1-9 with agreement as a median of > 7)
(The full guideline can be accessed at http://intensivecare.hsnet.nsw.gov.au/icwiki/index.php/Tracheostomy)

I would like to draw your attention in particular to Recommendation no 4 and the use of the terminology “clean procedure”.
This is because in my hospital, I am in the process of implementing the ANTT (aseptic non-touch technique) Clinical Practice Framework (The Association for Safe Clinical practice http://www.antt.org) in order to meet National Standard 3, criterion 3.10.1-3.10.3. ANTT does not recognise the term “clean procedure”. According to ANTT, the term clean refers to “free from marks and stains”. Therefore, the term clean technique and implied ‘clean’ aim can cause confusion and should be avoided; any lesser aim than asepsis for invasive clinical procedures and maintenance of invasive medical devices is potentially ethically and legally problematic.

I would like to know what your thoughts are with respect to this.
Rita Roy

Clinical Nurse Consultant | Infection Control
Hornsby Ku ring gai Health Service, Palmerston Road, Hornsby NSW 2077
Tel (02) 9477 9232 | Fax (02) 9477 9013 | Mob 0422 930 370 | Rita.Roy@health.nsw.gov.au
http://www.health.nsw.gov.au

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[Anonymous]

Hi Rita,

I agree they should use the ANTT terminology – I have suggested an
alternative

This procedure must be performed using Standard ANTT and staff must practice
hand hygiene before and after donning non-sterile gloves and wear
appropriate PPE e.g.; apron, full-face visor.

Regards

Terry McAuley

Sterilisation & Infection Prevention and Control Consultant

STEAM Consulting

E: terry@steamconsulting.com.au

W: http://www.steamconsulting.com.au

A: PO BOX 779

Endeavour Hills

VIC Australia 3802

CONFIDENTIAL COMMUNICATION: The information contained in this message may
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or entity named above. If the reader of this message is not the intended
recipient, you are hereby notified that any dissemination, distribution or
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Of Rita Roy

Dear All,

The Intensive Care and Coordination monitoring unit (ICCMU) is working on a
tracheostomy guideline. The recommendations around cleaning of the inner
cannulas are as in the table below:

Recommendations

Grade of Recommendation

1.

The inner cannula must be checked for patency, cleaned and replaced
2-4hourly. More frequent checks will depend on the volume and viscosity of
secretions.

Consensus

2.

The inner cannula should be cleaned and dried according to manufacturer’s
guidelines and stored in a clean dry container.

Consensus

3.

Under most circumstances the inner cannula can be cleaned with sterile water
with a tracheostomy cleaning brush or a pipe cleaner (with the end turned
over). Where secretions are tenacious, alternative solutions can be used;
however, the tube should not be soaked for more than 15 minutes.

Consensus

4.

This procedure is a clean procedure which requires hand hygiene before and
after donning appropriate PPE e.g.; gloves, apron, full-face visor.

Consensus

5.

It is inappropriate to clean or rinse the inner cannula at hand basins used
for hand washing because of the risk of contaminating the basin with
organisms or contamination of the inner cannula.

Consensus

6.

When placing a clean inner cannula into a TT tube it should be rinsed with
sterile water immediately prior to insertion.

Consensus

Consensus means that the guideline group & external validation panel agreed
on this recommendation (using a likert scale 1-9 with agreement as a median
of >= 7)

(The full guideline can be accessed at
http://intensivecare.hsnet.nsw.gov.au/icwiki/index.php/Tracheostomy)

I would like to draw your attention in particular to Recommendation no 4 and
the use of the terminology “clean procedure”.

This is because in my hospital, I am in the process of implementing the ANTT
(aseptic non-touch technique) Clinical Practice Framework (The Association
for Safe Clinical practice http://www.antt.org) in order to meet National Standard
3, criterion 3.10.1-3.10.3. ANTT does not recognise the term “clean
procedure”. According to ANTT, the term clean refers to “free from marks and
stains”. Therefore, the term clean technique and implied ‘clean’ aim can
cause confusion and should be avoided; any lesser aim than asepsis for
invasive clinical procedures and maintenance of invasive medical devices is
potentially ethically and legally problematic.

I would like to know what your thoughts are with respect to this.

Rita Roy

Clinical Nurse Consultant | Infection Control

Hornsby Ku ring gai Health Service, Palmerston Road, Hornsby NSW 2077
Tel (02) 9477 9232 | Fax (02) 9477 9013 | Mob 0422 930 370 |
Rita.Roy@health.nsw.gov.au
http://www.health.nsw.gov.au

http://internal.health.nsw.gov.au/communications/e-signatures/images/NSW-Hea
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[Julie Hunt]

Hi Rita,

I agree with Terry although I would use the terminology aseptic technique as the term ‘Aseptic Non
Touch Technique (ANTT)’ is copyrighted and the logo Trademarked.

This procedure must be performed using aseptic technique and staff must perform hand hygiene before and after donning non-sterile gloves and wear appropriate PPE e.g. apron, full-face visor

I agree that the use of sterile water for cleaning the inner tube is appropriate and recommend using a sterile dressing pack for the aseptic field and a sterile kidney dish to contain the water and place the inner tube when removed from the patient.

I also agree that use of a hand hygiene basin for this purpose is not appropriate due to the risk of colonisation of microorganisms from the device (hand hygiene basins should only be used for hand hygiene) and because a hand hygiene basin is not an appropriate field for aseptic technique.

Regards

Julie Hunt

Clinical Nurse Consultant
Infection Prevention & Control
Royal North Shore Hospital
Reserve Rd St Leonards 2065
Tel 02 99264339 or 99264490

Hi Rita,

I agree they should use the ANTT terminology – I have suggested an alternative

This procedure must be performed using Standard ANTT and staff must practice hand hygiene before and after donning non-sterile gloves and wear appropriate PPE e.g.; apron, full-face visor.

Regards
Terry McAuley
Sterilisation & Infection Prevention and Control Consultant
STEAM Consulting
E: terry@steamconsulting.com.au
W: http://www.steamconsulting.com.au
A: PO BOX 779
Endeavour Hills
VIC Australia 3802

CONFIDENTIAL COMMUNICATION: The information contained in this message may contain confidential information intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or duplication of this transmission is strictly prohibited. If you have received this communication in error, please notify us by telephone or email immediately and return the original message to us or destroy all printed and electronic copies. Nothing in this transmission constitutes an agreement of any kind unless otherwise expressly indicated.

Dear All,
The Intensive Care and Coordination monitoring unit (ICCMU) is working on a tracheostomy guideline. The recommendations around cleaning of the inner cannulas are as in the table below:

Recommendations

Grade of Recommendation

1.

The inner cannula must be checked for patency, cleaned and replaced 2-4hourly. More frequent checks will depend on the volume and viscosity of secretions.

Consensus

2.

The inner cannula should be cleaned and dried according to manufacturer’s guidelines and stored in a clean dry container.

Consensus

3.

Under most circumstances the inner cannula can be cleaned with sterile water with a tracheostomy cleaning brush or a pipe cleaner (with the end turned over). Where secretions are tenacious, alternative solutions can be used; however, the tube should not be soaked for more than 15 minutes.

Consensus

4.

This procedure is a clean procedure which requires hand hygiene before and after donning appropriate PPE e.g.; gloves, apron, full-face visor.

Consensus

5.

It is inappropriate to clean or rinse the inner cannula at hand basins used for hand washing because of the risk of contaminating the basin with organisms or contamination of the inner cannula.

Consensus

6.

When placing a clean inner cannula into a TT tube it should be rinsed with sterile water immediately prior to insertion.

Consensus

Consensus means that the guideline group & external validation panel agreed on this recommendation (using a likert scale 1-9 with agreement as a median of > 7)
(The full guideline can be accessed at http://intensivecare.hsnet.nsw.gov.au/icwiki/index.php/Tracheostomy)

I would like to draw your attention in particular to Recommendation no 4 and the use of the terminology “clean procedure”.
This is because in my hospital, I am in the process of implementing the ANTT (aseptic non-touch technique) Clinical Practice Framework (The Association for Safe Clinical practice http://www.antt.org) in order to meet National Standard 3, criterion 3.10.1-3.10.3. ANTT does not recognise the term “clean procedure”. According to ANTT, the term clean refers to “free from marks and stains”. Therefore, the term clean technique and implied ‘clean’ aim can cause confusion and should be avoided; any lesser aim than asepsis for invasive clinical procedures and maintenance of invasive medical devices is potentially ethically and legally problematic.

I would like to know what your thoughts are with respect to this.
Rita Roy

Clinical Nurse Consultant | Infection Control
Hornsby Ku ring gai Health Service, Palmerston Road, Hornsby NSW 2077
Tel (02) 9477 9232 | Fax (02) 9477 9013 | Mob 0422 930 370 | Rita.Roy@health.nsw.gov.au
http://www.health.nsw.gov.au

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This message is intended for the addressee named and may contain confidential information. If you are not the intended recipient, please delete it 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.

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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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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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This message is intended for the addressee named and may contain confidential information. If you are not the intended recipient, please delete it and notify the sender.

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[Anonymous]

Dear Beth,
Thank you for your reply. A standardised trache care kit would indeed be a good solution if as you say it could comply with ANTT, AS4187 and is TGA approved.
Rita

—–Original Message—–

Hi all

Apologies for my late arrival to the discussion and if this point has already been discussed.

To comply with An aseptic approach we need to have access to a sterile cannula brush or similar, this item doesn’t appear to be readily available in Australia. I have made a number of enquiries with ICU’s in NSW and they have all indicated unique local solutions which perhaps could benefit from the availability of a standardised trache care kit. These kits are available from a number of manufactures in the US but they are distributed within Australia.

In short, I would be interested in any equipment solutions for cleaning trache internal cannulae that comply ith ANNT, AS4187 and are TGA approved.

Thanks
Beth
Beth Bint

Infection Prevention and Control Clinical Nurse Consultant | Infection Management and Control Service Level 1 Lawson House Wollongong Hospital Tel 02 4222 5898 |beth.bint@SESIAHS.HEALTH.NSW.GOV.AU
http://www.health.nsw.gov.au
________________________________________

Dear Julie,
Thank you as always for your invaluable comments and advice. I had not had a chance to read Kaye’s response closely, but now have. Here at HKH, we have always done changing of inner cannulas of tracheostomies using aseptic technique and like you, I believe it is essential. Yes, the inner cannulas might be going into devices which are already heavily colonised, which is all the more reason not to increase that microbial load further and with possibly newer pathogens.
Again use of terminology such as sterile field will have to be replaced by terminology such as Critical Aseptic field and the like as according to ANTT, a sterile (definition: free from all living microorganisms) field cannot be typically achieved or maintained in healthcare settings.
So yes, a lot of food for thought.
Rita

Hi Rita,

I agree that inner cannulas are being inserted into devices that are already in place which may be heavily colonised. However, the reason for a sterile filed is to prevent the cannula itself from contamination with organisms from other parts of the patient and also from the environment.

I also agree that there is a difference between a device that goes into blood (critical device) and one which goes into the larynx (semi critical device), they are both types of invasive devices as per the TGA definition and I believe that aseptic technique applies to performing procedures related to both.

Cost effectiveness or a reusable cannula is something each HCF would have to determine and is not an argument for not using aseptic technique.

Regardless of the evidence for ANTT, to comply with Standard 3 of the National Safety and Quality Health Service Standards, HCFs have to meet requirements related both to aseptic technique and invasive devices when performing procedures such as these.

Regards

Julie Hunt

Clinical Nurse Consultant
Infection Prevention & Control
Royal North Shore Hospital
Reserve Rd St Leonards 2065
Tel 02 99264339 or 99264490

Dear Michael,
I think this discussion is important to circulate.
Many thanks,
Rita
Rita Roy

Clinical Nurse Consultant | Infection Control Hornsby Ku ring gai Health Service, Palmerston Road, Hornsby NSW 2077 Tel (02) 9477 9232 | Fax (02) 9477 9013 | Mob 0422 930 370 | Rita.Roy@health.nsw.gov.au
http://www.health.nsw.gov.au

[cid:image002.jpg@01CF32C6.CFF81850]

Thanks Rita
The feedback is great. I would be grateful if you could send my feedback through to the group

* Thanks to the group for looking at how we can improve this practice

* At present the Trache guideline is under implementation and we wont be changing recommendations for at least a year.

o This doesn’t mean however that at a local level the ICPs couldn’t partner with the trache leads to change this practice to reflect ANTT.

o The trach guideline was reviewed by 6 NSW ICPs as well as going through the usual organisational consultation processes

o The guideline can be found at http://intensivecare.hsnet.nsw.gov.au/icwiki/index.php/Tracheostomy

* I disagree the procedure needs to be aseptic but I do acknowledge the issues with terminology

o Inner cannulas are being inserted into devices that are already in place which will be heavily colonised.

o There is a difference between a device that goes into blood and one which goes into the larynx.

o The evidence base that I have seen for the effectiveness of ANTT in reducing infections is very limited.

* A sterile dressing pack may be appropriate as a sterile field

o IF you are using a disposable inner cannulae &/or

o Doing the dressing as part of the procedure (which would be entirely appropriate where you had a patient with a large amount of sputum and were need to do the dressing frequently OR a least for one change)

o The gully pots are not large enough for cleaning inner cannulas although a sterile kidney dish would be useful.

o Disposable inner cannulas are not going to be cost effective if you are having the change them frequently.

* However this would not be cost effective if you were using reusable inner cannulas. This procedure is quite quick when changing the inner cannulae. And the dirty inner cannulae cleaning can be moved away from the patients immediate bedside.

* There were such things as trach packs (back in the day) perhaps these could be investigated.

* I would appreciate if the ICPs could provide the evidence & rationale for changing from a clean technique to an aseptic technique.

o I don’t wish to be confrontational Im always happy to review new evidence and incorporate it into practice. It is easier to change the minds of ICU clinicians with evidence.

* It is important to realise this change in practice will be significant. At present the vast majority of hospitals undertake this procedure using a clean technique and many others continue to use the handbasin tap (yuck)

* The ICPs are going to need to partner with the trache leads to change this practice. I would suggest opening a dialogue with your local trach teams

I do appreciate the input of the ICP community and look forward to improving this practise

(Ill leave my opinions regarding the copyrighting of a commonly used clinical term to a later date)

Kaye Rolls
Clinical Project Officer – ICCMU | Agency for Clinical Innovation Level 4, Sage Building, 67 Albert Avenue, Chatswood NSW 2067 Postal Address: PO Box 699 Chatswood NSW 2057 Mobile 0423 607 735 | Tel. +61 2 9464 4692 | Fax. +61 2 9464 4728 | Kaye.Rolls@aci.health.nsw.gov.au
http://www.aci.health.nsw.gov.au | http://intensivecare.hsnet.nsw.gov.au

[cid:image001.jpg@01CF32C0.6183A200][cid:image003.jpg@01CF32C5.33967C00]

FYI

Hi Rita,

I agree with Terry although I would use the terminology aseptic technique as the term ‘Aseptic Non Touch Technique (ANTT)’ is copyrighted and the logo Trademarked.

This procedure must be performed using aseptic technique and staff must perform hand hygiene before and after donning non-sterile gloves and wear appropriate PPE e.g. apron, full-face visor

I agree that the use of sterile water for cleaning the inner tube is appropriate and recommend using a sterile dressing pack for the aseptic field and a sterile kidney dish to contain the water and place the inner tube when removed from the patient.

I also agree that use of a hand hygiene basin for this purpose is not appropriate due to the risk of colonisation of microorganisms from the device (hand hygiene basins should only be used for hand hygiene) and because a hand hygiene basin is not an appropriate field for aseptic technique.

Regards

Julie Hunt

Clinical Nurse Consultant
Infection Prevention & Control
Royal North Shore Hospital
Reserve Rd St Leonards 2065
Tel 02 99264339 or 99264490

Hi Rita,

I agree they should use the ANTT terminology – I have suggested an alternative

This procedure must be performed using Standard ANTT and staff must practice hand hygiene before and after donning non-sterile gloves and wear appropriate PPE e.g.; apron, full-face visor.

Regards
Terry McAuley
Sterilisation & Infection Prevention and Control Consultant STEAM Consulting
E: terry@steamconsulting.com.au
W: http://www.steamconsulting.com.au
A: PO BOX 779
Endeavour Hills
VIC Australia 3802

CONFIDENTIAL COMMUNICATION: The information contained in this message may contain confidential information intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or duplication of this transmission is strictly prohibited. If you have received this communication in error, please notify us by telephone or email immediately and return the original message to us or destroy all printed and electronic copies. Nothing in this transmission constitutes an agreement of any kind unless otherwise expressly indicated.

Dear All,
The Intensive Care and Coordination monitoring unit (ICCMU) is working on a tracheostomy guideline. The recommendations around cleaning of the inner cannulas are as in the table below:

Recommendations

Grade of Recommendation

1.

The inner cannula must be checked for patency, cleaned and replaced 2-4hourly. More frequent checks will depend on the volume and viscosity of secretions.

Consensus

2.

The inner cannula should be cleaned and dried according to manufacturer’s guidelines and stored in a clean dry container.

Consensus

3.

Under most circumstances the inner cannula can be cleaned with sterile water with a tracheostomy cleaning brush or a pipe cleaner (with the end turned over). Where secretions are tenacious, alternative solutions can be used; however, the tube should not be soaked for more than 15 minutes.

Consensus

4.

This procedure is a clean procedure which requires hand hygiene before and after donning appropriate PPE e.g.; gloves, apron, full-face visor.

Consensus

5.

It is inappropriate to clean or rinse the inner cannula at hand basins used for hand washing because of the risk of contaminating the basin with organisms or contamination of the inner cannula.

Consensus

6.

When placing a clean inner cannula into a TT tube it should be rinsed with sterile water immediately prior to insertion.

Consensus

Consensus means that the guideline group & external validation panel agreed on this recommendation (using a likert scale 1-9 with agreement as a median of > 7) (The full guideline can be accessed at http://intensivecare.hsnet.nsw.gov.au/icwiki/index.php/Tracheostomy)

I would like to draw your attention in particular to Recommendation no 4 and the use of the terminology “clean procedure”.
This is because in my hospital, I am in the process of implementing the ANTT (aseptic non-touch technique) Clinical Practice Framework (The Association for Safe Clinical practice http://www.antt.org) in order to meet National Standard 3, criterion 3.10.1-3.10.3. ANTT does not recognise the term “clean procedure”. According to ANTT, the term clean refers to “free from marks and stains”. Therefore, the term clean technique and implied ‘clean’ aim can cause confusion and should be avoided; any lesser aim than asepsis for invasive clinical procedures and maintenance of invasive medical devices is potentially ethically and legally problematic.

I would like to know what your thoughts are with respect to this.
Rita Roy

Clinical Nurse Consultant | Infection Control Hornsby Ku ring gai Health Service, Palmerston Road, Hornsby NSW 2077 Tel (02) 9477 9232 | Fax (02) 9477 9013 | Mob 0422 930 370 | Rita.Roy@health.nsw.gov.au
http://www.health.nsw.gov.au

[cid:image001.jpg@01CF316A.57430C60]

This message is intended for the addressee named and may contain confidential information. If you are not the intended recipient, please delete it 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.

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

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