Re Intermittant IV Antibiotic adminstration

[Chris Braden]

Hi Everyone,

I have an aversion to IV giving sets being disconnected from the patient
following intermittent antibiotic administration, connected to a hanging
IV bag and reconnected to the patient 6 hours + when the next Anti is
due.

Wondering if anyone can point me in the right direction for some
evidence for support or am I being pedantic?

Regards

Chris

Christine Braden

Manager Infection Control

Djerriwarrh Health Service

Email- chrisb@djhs.org.au

Ph- 53 67 2000

Mobile – 0402 242 651

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[Claire Rickard]

Hi Christine

I agree, this DRIVES ME NUTS.

This was published in the RCNA magazine last year…hope it’s of some use…

*Routine disconnection of continuous intravenous therapy: implications for
your patients recovery*

*By Amanda Ullman and Nicole Marsh*

*A patient under your care who is currently receiving continuous
intravenous therapy wants to have a shower. In order to facilitate this,
you disconnect their IV from their infusion, right? No.*

Nurses who disconnect their patients IV tubing during continuous
intravenous therapy are trying to be flexible and accommodating, however
this practice may have a significant impact on the patients health and
recovery says Professor Rickard (FRCNA), a leading nurse researcher in the
field of Intravascular Device (IVD) management from the Griffith Health
Institutes NHMRC Centre of Research Excellence in Nursing.

In earlier times it was commonplace to see ambulant patients pushing their
IV drip poles around hospital corridors. Nowadays, it seems to have become
the unofficial, but standard practice to disconnect IV tubing while
patients have showers, or just go for a walk said Rickard Its really
commonplace now to see disconnected IV tubing lying on patients beds, or
hooked onto IV poles. Its quite concerning because maintaining sterility
of IV circuits is vital in preventing infection, and theres also issues in
interrupting prescribed therapy.

To overcome infection control concerns, some wards discard the disconnected
tubing, and then replace this with new sterile fluids and tubing when the
patient returns. But its still not good enough according to Professor
Rickard. She says with hospital budgets as they are, we cant afford to be
routinely discarding expensive disposable equipment, not to mention
infusion fluids and drugs, sometimes even parenteral nutrition. If we just
left the lines intact, hospitals would literally save tens of thousands of
dollars off their budgets each year.

Another trend in therapy has been for nurses to use a new 100mL normal
saline fluid bag and IV tubing set for each dose of intermittent
antibiotics. This supersedes the earlier practice of leaving a 1000mL bag
and line attached to the IVD, with a burette in the circuit used for
medication doses, with the saline infusing slowly in between doses. Again,
Rickard questions whether this has been progress or a backwards step.

Hanging a new 100ml bag and administration set for a sixth hourly
antibiotic costs $44.36, compared with leaving a 1 litre bag and line
connected which costs $9.15 says Rickard. The main problem though is not
expense, its the repeated interruptions to the circuit. This approach
means the IVD hub, a common source of infection, is handled eight times a
day, compared to no handling with the use of a keep vein open litre bag
and line. Theres no way we can guarantee that all staff are going to take
the time to properly undertake hand hygiene, decontaminate the connectors
with alcoholic chlorhexidine (plus letting it dry), before accessing the
system on all occasions.

Intravenous therapy is defined as a set of knowledge and techniques aimed
at administering solutions or drugs in the circulatory system and covers
different care aspects, ranging from the patients preparation to
intervention in the event of complications to obtaining the desired outcome
(Jacinto, Avelar, & Pedreira,
2011).
It comprises interventions that are complex and can lead to complications
that can jeopardize patient safety (Jacinto et al.,
2011
).

Continuous intravenous therapy can run for hours, days or weeks. When
continuous intravenous therapy is disconnected, the nurse is altering the
patient’s ability to reach therapeutic goals (Webster, Osborne, Rickard, &
Hall, 2010).
This variation in therapy may have an adverse effect on the patients
clinical condition and long-term outcomes. This is impacted by the
medications or fluids being administered, but as a minimum it will have an
impact on the patients fluid and electrolyte balance.

The frequent disconnection of intravenous administration sets from the IVD
may also increase the ability of potentially infection-causing bacteria to
contaminate and colonise the IVD hub. This bacterium may then potentially
enter the blood-stream causing systemic infection (O’Grady et al.,
2011).

In addition to contamination, there is the risk of accidentally connecting
the wrong tubing back to the IVD. There are numerous adverse events
documented in literature, including patient deaths, from tubing
misconnections.

The main reason for disconnecting an IVD receiving a continuous infusion
should be to discontinue therapy, routinely change the administration sets
at between four and seven days, (24hourly for blood, blood products, fat
emulsions or propofol) (O’Grady et al.,
2011)
or in an emergency.

Professor Rickard says all nurses have a responsibility to provide
evidence-based practice to their patients. The routine interruption of
continuous intravenous therapy is not beneficial to our patients.

*References*

Jacinto, A., Avelar, A., & Pedreira, M. (2011). Predisposing factors for
infiltration in children submitted to peripheral venous
catheterization. *Journal
of Infusion Nursing, 34*(6), 391-398.

O’Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J.,
O’Heard, S., . . . Healthcare Infection Control Practices Advisory
Committee (HICPAC). (2011). Guidelines for the prevention of intravascular
catheter-related infections. *Clinical Infectious Diseases, 52*(9),
e162-193.

Webster, J., Osborne, S., Rickard, C., & Hall, J. (2010).
Clinically-indicated replacement versus routine replacement of peripheral
venous catheters. *Cochrane Database of Systematic Reviews, 17*(3),
CD007798.

Best regards, Claire

*Professor Claire Rickard RN PhD*
*Assistant: Jo Wright *Jo.Wright@griffith.edu.au +61 (0)7 3735 4886 (ext
54886)

c.rickard@griffith.edu.au | +61 (0)7 3735 6460 | Skype:
clairexm1 | Twitter: IVAD_Research |
http://www.griffith.edu.au/health/centre-health-practice-innovation/research/acute-critical-care/intravascular-devices

Australian Vascular Access Teaching and Research Group | NHMRC Centre of
Research Excellence in Nursing Interventions | Griffith Health Institute
Centre for Health Practice Innovation | Royal Brisbane & Women’s
Hospital | Princess
Alexandra Hospital | The Prince Charles Hospital

Research frequently takes me off campus. Please contact
Jo.Wright@griffith.edu.au 3735 4886, or the School Secretary (Nathan) Jenny
Chan 3735 5406 *j.chan@griffith.edu.au* for urgent
enquiries.

*It’s nice to be important, but it’s more important to be nice. John Cassis.
*

On 23 August 2013 14:05, Chris Braden wrote:

> Hi Everyone,****
>
> ** **
>
> I have an aversion to IV giving sets being disconnected from the patient
> following intermittent antibiotic administration, connected to a hanging IV
> bag and reconnected to the patient 6 hours + when the next Anti is due.***
> *
>
> Wondering if anyone can point me in the right direction for some evidence
> for support or am I being pedantic?****
>
> ** **
>
> Regards****
>
> Chris****
>
> ** **
>
> Christine Braden****
>
> Manager Infection Control****
>
> Djerriwarrh Health Service****
>
> Email- chrisb@djhs.org.au****
>
> Ph- 53 67 2000****
>
> Mobile – 0402 242 651****
>
> ** **
> 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
>

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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[Tim Spencer]

The Prof has spoken..

I would have said and referred the same.

Here are a few current guideline statements.

CDC Guidelines Statement; (p. 53)

Replacement of Administration Sets

Recommendations

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

3. No recommendation can be made regarding the frequency for replacing
needles to access implantable ports. Unresolved issue

4. Replace tubing used to administer blood, blood products, or fat
emulsions (those combined with amino acids and glucose in a 3-in-1
admixture or infused separately) within 24 hours of initiating the
infusion [182-185]. Category IB

5. Replace tubing used to administer propofol infusions every 6 or 12
hours, when the vial is changed, per the manufacturer’s recommendation
(FDA website Medwatch) *186+. Category IA

6. No recommendation can be made regarding the length of time a needle
used to access implanted ports can remain in place. Unresolved issue

INS Guidelines Statement;

43. ADMINISTRATION SET CHANGE (p. S55)

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)

Another reference of use is below;

McDonald LC, Banerjee SN, Jarvis WR. Line-associated bloodstream
infections in pediatric intensive-care-unit patients associated with a
needleless device and intermittent intravenous therapy. Infect Control
Hosp Epidemiol 1998; 19:772-7.

Regards,

Tim..

Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition
Service

Conjoint Lecturer, South West Sydney Clinical School | Faculty of
Medicine | University of NSW
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital,
Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 |
Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au

Behalf Of Claire Rickard

Hi Christine

I agree, this DRIVES ME NUTS.

This was published in the RCNA magazine last year…hope it’s of some
use…

Routine disconnection of continuous intravenous therapy: implications
for your patients’ recovery

By Amanda Ullman and Nicole Marsh

A patient under your care who is currently receiving continuous
intravenous therapy wants to have a shower. In order to facilitate this,
you disconnect their IV from their infusion, right? No.

“Nurses who disconnect their patients’ IV tubing during continuous
intravenous therapy are trying to be flexible and accommodating, however
this practice may have a significant impact on the patients’ health and
recovery” says Professor Rickard (FRCNA), a leading nurse researcher in
the field of Intravascular Device (IVD) management from the Griffith
Health Institute’s NHMRC Centre of Research Excellence in Nursing.

In earlier times it was commonplace to see ambulant patients pushing
their IV drip poles around hospital corridors. “Nowadays, it seems to
have become the unofficial, but standard practice to disconnect IV
tubing while patients have showers, or just go for a walk” said Rickard
“It’s really commonplace now to see disconnected IV tubing lying on
patients’ beds, or hooked onto IV poles. It’s quite concerning because
maintaining sterility of IV circuits is vital in preventing infection,
and there’s also issues in interrupting prescribed therapy’.

To overcome infection control concerns, some wards discard the
disconnected tubing, and then replace this with new sterile fluids and
tubing when the patient returns. But it’s still not good enough
according to Professor Rickard. She says “with hospital budgets as they
are, we can’t afford to be routinely discarding expensive disposable
equipment, not to mention infusion fluids and drugs, sometimes even
parenteral nutrition. If we just left the lines intact, hospitals would
literally save tens of thousands of dollars off their budgets each
year”.

Another trend in therapy has been for nurses to use a new 100mL normal
saline fluid bag and IV tubing set for each dose of intermittent
antibiotics. This supersedes the earlier practice of leaving a 1000mL
bag and line attached to the IVD, with a burette in the circuit used for
medication doses, with the saline infusing slowly in between doses.
Again, Rickard questions whether this has been progress or a backwards
step.

“Hanging a new 100ml bag and administration set for a sixth hourly
antibiotic costs $44.36, compared with leaving a 1 litre bag and line
connected which costs $9.15” says Rickard. The main problem though is
not expense, it’s the repeated interruptions to the circuit. “This
approach means the IVD hub, a common source of infection, is handled
eight times a day, compared to no handling with the use of a ‘keep vein
open’ litre bag and line. There’s no way we can guarantee that all staff
are going to take the time to properly undertake hand hygiene,
decontaminate the connectors with alcoholic chlorhexidine (plus letting
it dry), before accessing the system on all occasions”.

Intravenous therapy is defined as a set of knowledge and techniques
aimed at administering solutions or drugs in the circulatory system and
covers different care aspects, ranging from the patient’s preparation to
intervention in the event of complications to obtaining the desired
outcome (Jacinto, Avelar, & Pedreira, 2011

). It comprises interventions that are complex and can lead to
complications that can jeopardize patient safety (Jacinto et al., 2011

).

Continuous intravenous therapy can run for hours, days or weeks. When
continuous intravenous therapy is disconnected, the nurse is altering
the patient’s ability to reach therapeutic goals (Webster, Osborne,
Rickard, & Hall, 2010

). This variation in therapy may have an adverse effect on the patient’s
clinical condition and long-term outcomes. This is impacted by the
medications or fluids being administered, but as a minimum it will have
an impact on the patients’ fluid and electrolyte balance.

The frequent disconnection of intravenous administration sets from the
IVD may also increase the ability of potentially infection-causing
bacteria to contaminate and colonise the IVD hub. This bacterium may
then potentially enter the blood-stream causing systemic infection (
O’Grady et al., 2011

).

In addition to contamination, there is the risk of accidentally
connecting the wrong tubing back to the IVD. There are numerous adverse
events documented in literature, including patient deaths, from tubing
misconnections.

The main reason for disconnecting an IVD receiving a continuous infusion
should be to discontinue therapy, routinely change the administration
sets at between four and seven days, (24hourly for blood, blood
products, fat emulsions or propofol) (O’Grady et al., 2011
)
or in an emergency.

Professor Rickard says “all nurses have a responsibility to provide
evidence-based practice to their patients. The routine interruption of
continuous intravenous therapy is not beneficial to our patients”.

References

Jacinto, A., Avelar, A., & Pedreira, M. (2011). Predisposing factors for
infiltration in children submitted to peripheral venous catheterization.
Journal of Infusion Nursing, 34(6), 391-398.

O’Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland,
J., O’Heard, S., . . . Healthcare Infection Control Practices Advisory
Committee (HICPAC). (2011). Guidelines for the prevention of
intravascular catheter-related infections. Clinical Infectious Diseases,
52(9), e162-193.

Webster, J., Osborne, S., Rickard, C., & Hall, J. (2010).
Clinically-indicated replacement versus routine replacement of
peripheral venous catheters. Cochrane Database of Systematic Reviews,
17(3), CD007798.

Best regards, Claire

Professor Claire Rickard RN PhD

54886)

c.rickard@griffith.edu.au | +61 (0)7 3735 6460 | Skype: clairexm1 |

http://www.griffith.edu.au/health/centre-health-practice-innovation/rese
arch/acute-critical-care/intravascular-devices

Australian Vascular Access Teaching and Research Group | NHMRC Centre of
Research Excellence in Nursing Interventions | Griffith Health Institute
Centre for Health Practice Innovation | Royal Brisbane & Women’s
Hospital | Princess Alexandra Hospital | The Prince Charles Hospital

Research frequently takes me off campus. Please contact
Jo.Wright@griffith.edu.au 3735 4886,
or the School Secretary (Nathan) Jenny Chan 3735 5406
j.chan@griffith.edu.au for urgent
enquiries.

It’s nice to be important, but it’s more important to be nice. John
Cassis.

On 23 August 2013 14:05, Chris Braden wrote:

Hi Everyone,

I have an aversion to IV giving sets being disconnected from the patient
following intermittent antibiotic administration, connected to a hanging
IV bag and reconnected to the patient 6 hours + when the next Anti is
due.

Wondering if anyone can point me in the right direction for some
evidence for support or am I being pedantic?

Regards

Chris

Christine Braden

Manager Infection Control

Djerriwarrh Health Service

Email- chrisb@djhs.org.au

Ph- 53 67 2000

Mobile – 0402 242 651

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

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
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Sydney & South Western Sydney Local Health Districts regularly monitor email and attachments to ensure compliance with the NSW Ministry of Health’s Electronic Messaging Policy.

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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[Author]

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