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Dear colleagues,
I am interested to know if Australian hospitals are routinely using wipes containing chlorhexidine 2% with alcohol 70% to disinfect vascular access hubs (i.e. to ‘scrub the hub’). In particular, is this practised on general wards when accessing a PIVC?
Many thanks,
DanielaDaniela Karanfilovska
Clinical Nurse Consultant
Infection Prevention & Healthcare Epidemiologyt 03 90762819 m 0427 703 769
e D.Karanfilovska@alfred.org.auAlfred Health
55 Commercial Road
Melbourne VIC 3004
PO Box 315 Prahran
VIC 3181 Australia
[cid:image001.jpg@01D40F93.50FEC4F0]
Alfred Health incorporates The Alfred, Caulfield Hospital, Sandringham Hospital and Melbourne Sexual Health Centre
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Hi Daniela
We do not routinely encourage use of chlorhexidine and alcohol wipes for access device swabbing, only 70% alcohol wipes. The rationale is that no residual effect is required. We do not prevent use of chlorhexidine containing swab for access devices, but we do not encourage it.
Cheers
MichaelMichael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
ph: 07 3326 3068 Email: michael.wishart@svha.org.au________________________________
Dear colleagues,
I am interested to know if Australian hospitals are routinely using wipes containing chlorhexidine 2% with alcohol 70% to disinfect vascular access hubs (i.e. to scrub the hub). In particular, is this practised on general wards when accessing a PIVC?
Many thanks,
DanielaDaniela Karanfilovska
Clinical Nurse Consultant
Infection Prevention & Healthcare Epidemiologyt 03 90762819 m 0427 703 769
e D.Karanfilovska@alfred.org.auAlfred Health
55 Commercial Road
Melbourne VIC 3004
PO Box 315 Prahran
VIC 3181 Australia
[cid:image001.jpg@01D40F93.50FEC4F0]
Alfred Health incorporates The Alfred, Caulfield Hospital, Sandringham Hospital and Melbourne Sexual Health Centre
http://www.alfredhealth.org.auCONFIDENTIALITY NOTICE: This email and any files transmitted with it are confidential and are to be used solely by the individual or entity to whom it is addressed. If you have received this email in error, please be aware that any disclosure, copying or distribution of the information it contains; or taking any action in reliance on the contents of this information, is strictly prohibited and may be unlawful. Please notify us by return email that you have received the email and delete all copies in your system.
Please consider the environment before printing this email.
______________________________________________________________________
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______________________________________________________________________
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Dear Daniella
I recently reviewed evidence and guidelines for best practice with vascular access devices. Below are the recommendations I made on based on the review and the supporting references.
I have never understood Australia’s reluctance to adopt scrub the hub campaigns and lack of interest in routine use of protective IV caps. As a recently hospitalised and immunosuppressed patient I worried every time my line was accessed as there was nothing uniform in any of the accesses. There are now good Australian research papers showing risk with even simple peripheral vascular catheters. IVs are inserted very commonly making them one of the most frequent infection risks in acute care settings.
With regard to CHG I also note a general reluctance to its use in Australia as evidenced by poor recommendations in the draft NHMRC IC Guidelines, questions raised previously on this discussion forum and at ACIPC meetings. Personally I disagree with Michael’s earlier comment given that it is often a long time between accesses of IV lines and if oncovered they can easily become contaminated hence an agent containing alcohol and CHG is safe to use in non CHG-sensitive populations and it gives immediacy plus residual. As you would appreciate CHG has been used extensively in healthcare and domestic settings for decades. True CHG sensitivity is extremely rare. Anaphylaxis reports typically demonstrate multi-site simultaneous exposure to CHG ie surgical skin prep + use of CHG lubricant jelly + CHG impregnated CVC insertion. The NHMRC’s recommendation that we keep risk registries of CHG containing products is salient as is the recommendation to take adequate histories from patients regarding sensitivities.
In a recent report where he considered “resistance” Kampf argued that we should use CHG cautiously and perhaps even in a stewardship way. He was smart to recognise that there is no universal agreed definition of CHG-resistance and that the mechanisms are very different to antimicrobial resistance.
I expect many will disagree with my views but I am very happy that CHG was used extensively to help prevent infection in my recent surgery and hospitalisation. I would have warmly welcomed the use of routine CHG & alcohol hub disinfection.
Recommendations based on literature and guideline review.
Care must be taken not to contaminate the lines when accessing lines and their administration sets.1,65,72
A single patient use application of 70% alcohol alone1,73 or >0.5% chlorhexidine in 70% alcohol1,10,29,72 should be used70 for 529- 15 seconds1,10,73 and allowed to dry when decontaminating the catheter hub or injection ports prior to every access of the circuit. This includes every time an infusion set is added or removed, as well as administration of medication.10,65 Supplies for disinfecting should be kept at the bedside.1
Use of disinfection caps on peripheral and central catheters should be considered.1,72
1. Gorski LA, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;39(1S):1-256.
10. Loveday HP, Wilson JA, Pratt RJ, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2014;86 Suppl 1:S1-70.
29. Marschall J, Mermel LA, Fakih M, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(7):753-771.
65. Society. AaNZIC. Central Line Insertion and Maintenance Guideline. 2012; http://www.anzics.com.au/Downloads/ANZICS_Insertion%26maintenance_guideline2012_04.pdf, 2017.
70. Ling ML, Apisarnthanarak A, Jaggi N, et al. APSIC guide for prevention of Central Line Associated Bloodstream Infections (CLABSI). Antimicrob Resist Infect Control Antimicrobial Resistance & Infection Control. 2016;5(1).
72. Nursing. RCo. Standards for infusion therapy. London.: Royal College of Nursing.; 2016.
73. (INICC). INICC. International Nosocomial Infection Control Consortium (INICC) Bundle to Prevent Central Line Associated Bloodstream Infections (CLAB) in Intensive Care Units (ICU): An International Perspective. Argentina.2017.
Cath
Cathryn Murphy RN B. Photog MPH CIC FAPIC FSHEA CICP-E PhD
Chief Executive Officer & Creative Director
Infection Control Plus Pty Ltd
Adjunct Associate Professor
Faculty of Health Sciences and Medicine, Bond University
QLD, AustraliaE: Cath@infectioncontrolplus.com.au
M: +61 428 154154
W:http://www.infectioncontrolplus.com.auDear colleagues,
I am interested to know if Australian hospitals are routinely using wipes containing chlorhexidine 2% with alcohol 70% to disinfect vascular access hubs (i.e. to ‘scrub the hub’). In particular, is this practised on general wards when accessing a PIVC?
Many thanks,
DanielaDaniela Karanfilovska
Clinical Nurse Consultant
Infection Prevention & Healthcare Epidemiologyt 03 90762819 m 0427 703 769
e D.Karanfilovska@alfred.org.auAlfred Health
55 Commercial Road
Melbourne VIC 3004
PO Box 315 Prahran
VIC 3181 Australia
[cid:image001.jpg@01D40F93.50FEC4F0]
Alfred Health incorporates The Alfred, Caulfield Hospital, Sandringham Hospital and Melbourne Sexual Health Centre
http://www.alfredhealth.org.auCONFIDENTIALITY NOTICE: This email and any files transmitted with it are confidential and are to be used solely by the individual or entity to whom it is addressed. If you have received this email in error, please be aware that any disclosure, copying or distribution of the information it contains; or taking any action in reliance on the contents of this information, is strictly prohibited and may be unlawful. Please notify us by return email that you have received the email and delete all copies in your system.
Please consider the environment before printing this email.
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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Hi Cath
I still have not seen definitive evidence that equates hub scrubbing with chlorhexidine containing swabs as being more effective than just 70% alcohol swabs for prevention of line infections.
The 2016 INS guidelines state:
F. Perform a vigorous mechanical scrub for manual disinfection of the needleless connector prior to each VAD access and allow it to dry.
1. Acceptable disinfecting agents include 70% isopropyl alcohol, iodophors (ie, povidone-iodine), or >0.5% chlorhexidine in alcohol solution. 7,16 (II)
2. Length of contact time for scrubbing and drying depends on the design of the needleless connector and the properties of the disinfecting agent. For 70% isopropyl alcohol, reported scrub times range from 5 to 60 seconds with biocide activity occurring when the solution is wet and immediately after drying. More research is needed for other agents or combinations of agents due to conflicting reports regarding the optimal scrub time. 3,17,18 (II)
3. Use vigorous mechanical scrubbing methods even when disinfecting needleless connectors with antimicrobial properties (eg, silver coatings). 19-24 (IV)
G. Use of passive disinfection caps containing disinfecting agents (eg, isopropyl alcohol) has been shown to reduce intraluminal microbial contamination and reduce the rates of central line-associated bloodstream
infection (CLABSI). Use of disinfection caps on peripheral catheters has limited evidence but should be considered.I do agree that staff confusion is an issue, so one product should be selected and made available. But until I see credible evidence to support use of chlorhexidine containing swabs on hubs, I will continue to promote 70% alcohol ‘scrub the hub’.
My opinion, anyway.
Cheers
MichaelMichael Wishart, CICP-E
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
[cid:image001.png@01D411E2.43F7A050] [cid:image002.png@01D411E2.43F7A050]
P Please consider the environment before printing this emailHi All,
Agree with Cath.Historically we stocked both 70% alcohol & the alcohol 2% CHG swabs / solution in clinical areas
After reviewing & auditing accessing devices it became quite clear that staff were confused about what to scrub the hub with or for insertion of a PIVC etc.
There was a lack of standardisation amongst staff about what product to use on which vascular access device when asked,
More frighteningly, staff also often referred to swabs according to the colour of the packet not the antiseptic solution – ‘use the blue swabs’ / ‘use the pink swabs’ / ‘use the orange swabs’.
To further complicate things – the colours of the swab packets can change depending on the supplier of the product. & at one point the alcohol swabs were virtually the same colour as the CHG swabs.
Chinese whispers were also a problem as some staff had heard about CHG sensitivity either in a journal, TV, Dr Google or at a conference & were taking it upon themselves & influencing others to use alcohol only which was not procedure.Using a risk management approach – 1st rule of thumb Eliminate!
The decision was made by the LHF to remove the alcohol swabs from all patient units & only stock alcohol CHG unless the clinical area identified a specific need for just alcohol swabs.
The risk of infection due to staff not using the correct antisepsis solution to scrub the hub or insertion far out-weighs the sensitivity issue for CHG.Cheers
Catherine WadeClinical Nurse Consultant | Infection Prevention & Control (IPAC)
Level 1 / 67 Holden Street, GOSFORD NSW 2250
Fax:(02) 4320 2874 | Internal Fax: 92874
Catherine.Wade@health.nsw.gov.au or CCLHD-IPAC@health.nsw.gov.au[http://internal.health.nsw.gov.au/communications/e-signatures/images/NSW-Health-Central-Coast-LHD.jpg]
Dear Daniella
I recently reviewed evidence and guidelines for best practice with vascular access devices. Below are the recommendations I made on based on the review and the supporting references.
I have never understood Australia’s reluctance to adopt scrub the hub campaigns and lack of interest in routine use of protective IV caps. As a recently hospitalised and immunosuppressed patient I worried every time my line was accessed as there was nothing uniform in any of the accesses. There are now good Australian research papers showing risk with even simple peripheral vascular catheters. IVs are inserted very commonly making them one of the most frequent infection risks in acute care settings.
With regard to CHG I also note a general reluctance to its use in Australia as evidenced by poor recommendations in the draft NHMRC IC Guidelines, questions raised previously on this discussion forum and at ACIPC meetings. Personally I disagree with Michael’s earlier comment given that it is often a long time between accesses of IV lines and if oncovered they can easily become contaminated hence an agent containing alcohol and CHG is safe to use in non CHG-sensitive populations and it gives immediacy plus residual. As you would appreciate CHG has been used extensively in healthcare and domestic settings for decades. True CHG sensitivity is extremely rare. Anaphylaxis reports typically demonstrate multi-site simultaneous exposure to CHG ie surgical skin prep + use of CHG lubricant jelly + CHG impregnated CVC insertion. The NHMRC’s recommendation that we keep risk registries of CHG containing products is salient as is the recommendation to take adequate histories from patients regarding sensitivities.
In a recent report where he considered “resistance” Kampf argued that we should use CHG cautiously and perhaps even in a stewardship way. He was smart to recognise that there is no universal agreed definition of CHG-resistance and that the mechanisms are very different to antimicrobial resistance.
I expect many will disagree with my views but I am very happy that CHG was used extensively to help prevent infection in my recent surgery and hospitalisation. I would have warmly welcomed the use of routine CHG & alcohol hub disinfection.
Recommendations based on literature and guideline review.
Care must be taken not to contaminate the lines when accessing lines and their administration sets.1,65,72
A single patient use application of 70% alcohol alone1,73 or >0.5% chlorhexidine in 70% alcohol1,10,29,72 should be used70 for 529- 15 seconds1,10,73 and allowed to dry when decontaminating the catheter hub or injection ports prior to every access of the circuit. This includes every time an infusion set is added or removed, as well as administration of medication.10,65 Supplies for disinfecting should be kept at the bedside.1
Use of disinfection caps on peripheral and central catheters should be considered.1,72
1. Gorski LA, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;39(1S):1-256.
10. Loveday HP, Wilson JA, Pratt RJ, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2014;86 Suppl 1:S1-70.
29. Marschall J, Mermel LA, Fakih M, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(7):753-771.
65. Society. AaNZIC. Central Line Insertion and Maintenance Guideline. 2012; http://www.anzics.com.au/Downloads/ANZICS_Insertion%26maintenance_guideline2012_04.pdf, 2017.
70. Ling ML, Apisarnthanarak A, Jaggi N, et al. APSIC guide for prevention of Central Line Associated Bloodstream Infections (CLABSI). Antimicrob Resist Infect Control Antimicrobial Resistance & Infection Control. 2016;5(1).
72. Nursing. RCo. Standards for infusion therapy. London.: Royal College of Nursing.; 2016.
73. (INICC). INICC. International Nosocomial Infection Control Consortium (INICC) Bundle to Prevent Central Line Associated Bloodstream Infections (CLAB) in Intensive Care Units (ICU): An International Perspective. Argentina.2017.
Cath
Cathryn Murphy RN B. Photog MPH CIC FAPIC FSHEA CICP-E PhD
Chief Executive Officer & Creative Director
Infection Control Plus Pty Ltd
Adjunct Associate Professor
Faculty of Health Sciences and Medicine, Bond University
QLD, AustraliaE: Cath@infectioncontrolplus.com.au
M: +61 428 154154
W:http://www.infectioncontrolplus.com.auDear colleagues,
I am interested to know if Australian hospitals are routinely using wipes containing chlorhexidine 2% with alcohol 70% to disinfect vascular access hubs (i.e. to ‘scrub the hub’). In particular, is this practised on general wards when accessing a PIVC?
Many thanks,
DanielaDaniela Karanfilovska
Clinical Nurse Consultant
Infection Prevention & Healthcare Epidemiologyt 03 90762819 m 0427 703 769
e D.Karanfilovska@alfred.org.auAlfred Health
55 Commercial Road
Melbourne VIC 3004
PO Box 315 Prahran
VIC 3181 Australia
[cid:image001.jpg@01D40F93.50FEC4F0]
Alfred Health incorporates The Alfred, Caulfield Hospital, Sandringham Hospital and Melbourne Sexual Health Centre
http://www.alfredhealth.org.auCONFIDENTIALITY NOTICE: This email and any files transmitted with it are confidential and are to be used solely by the individual or entity to whom it is addressed. If you have received this email in error, please be aware that any disclosure, copying or distribution of the information it contains; or taking any action in reliance on the contents of this information, is strictly prohibited and may be unlawful. Please notify us by return email that you have received the email and delete all copies in your system.
Please consider the environment before printing this email.
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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______________________________________________________________________
This email and any attachments to it (the “Email”) is confidential and is for the use only of the intended recipient, and may not be duplicated or used by any other party without the express consent of the sender. If you are not the intended recipient of the Email, please notify the sender immediately by return email, delete the Email, and do not copy, print, retransmit, store or act in reliance on the Email. St Vincent’s Health Australia (“SVHA”) does not guarantee that the Email is free from errors, viruses or interference. Emails to and from SVHA or its related entities may be scanned and filtered in locations outside Australia.MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
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Dear Daniela
Great question! Julie Flynn, a colleague with AVATAR (Alliance for Vascular Access and Teaching, Queensland) and RBH&W Hospital is doing her PhD on the disinfection of needleless connectors. She recently published a letter to the editor on exactly this in the American Journal of Infection Prevention, 2018. Please find attached.
Thanks
Kind regardsKerrie
KERRIE CURTIS
Project Manager: The Lines Project
A PICS, Royal Children’s Hospital and Monash Children’s Hospital Collaboration.[PICS_logo_rgb_hires]
Administrative Host:
The Royal Children’s Hospital
1st Floor South Building | 50 Flemington Rd | Parkville | Victoria | 3052
P| 03 9345 5021 F| 03 9345 9165
E| Kerrie.curtis@rch.org.au W| http://www.pics.org.auDear colleagues,
I am interested to know if Australian hospitals are routinely using wipes containing chlorhexidine 2% with alcohol 70% to disinfect vascular access hubs (i.e. to ‘scrub the hub’). In particular, is this practised on general wards when accessing a PIVC?
Many thanks,
DanielaDaniela Karanfilovska
Clinical Nurse Consultant
Infection Prevention & Healthcare Epidemiologyt 03 90762819 m 0427 703 769
e D.Karanfilovska@alfred.org.auAlfred Health
55 Commercial Road
Melbourne VIC 3004
PO Box 315 Prahran
VIC 3181 Australia
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Alfred Health incorporates The Alfred, Caulfield Hospital, Sandringham Hospital and Melbourne Sexual Health Centre
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Hi All,
I think the other thing to consider is the human factors that influence the staff.Many staff are unaware of the current evidence pertaining to scrub the hub (in relation to the INS SOP), and while there has been somewhat limited high-level published evidence, there is sufficient to support for the correct solution and time to scrub.
Much of it comes down to the correct scrubbing technique. There was a video we made for ACI several years ago on scrub the hub demonstrating this. Kaye Rolls (?) is it still around?
Not only is this lack of understanding confusing to floor clinicians, but the confusion behind changing of needlefree connectors etc reigns just as high on the list.
The INS SOP states that either 70% IPA or >0.5% CHG + 70% IPA swabs. This is used for device access/de-accessing.
If you are talking about the cap covers that are attached to provide a passive protection, then IPA is all that is required (INS SOP) as this provides for intraluminal microbial contamination.
Scrubbing solution and time of scrub (5-15secs) has been studied previously and is included in INS SOP.
–
INS SOP – Section 6
Standard
34.1 Use a luer-locking mechanism to ensure a secure junction when attaching needleless connectors to a vas- cular access device (VAD) hub or access site.
34.2 Disinfect needleless connectors prior to each entry into the device.
34.3 Use aseptic no-touch technique to change the needleless connector.
34.4 Access needleless connectors only with a sterile device.This should also be in conjunction with the needlefree device manufacturers IFU. see below for more details..
E. Follow manufacturers directions for the appropriate sequence of catheter clamping and final syringe disconnection to reduce the amount of blood reflux into the VAD lumen and, thus, the incidence of intraluminal thrombotic occlusion. The sequence for flushing, clamping, and disconnecting the syringe depends upon the internal mechanism for fluid dis- placement. Standardizing the type of needleless connector within the organization may reduce risk for confusion about these steps and improve out- comes.14,15 (V)
F. Perform a vigorous mechanical scrub for manual disinfection of the needleless connector prior to each VAD access and allow it to dry.
1. Acceptable disinfecting agents include 70% iso-propyl alcohol, iodophors (ie, povidone-iodine), or >0.5% chlorhexidine in alcohol solution.7,16 (II)
2. Length of contact time for scrubbing and drying depends on the design of the needleless connector and the properties of the disinfecting agent. For from 5 to 60 seconds with biocide activity occurring when the solution is wet and immediately after drying. More research is needed for other agents or combinations of agents due to conflicting reports regarding the optimal scrub time.3,17,18 (II)
3. Use vigorous mechanical scrubbing methods even when disinfecting needleless connectors with antimicrobial properties (eg, silver coatings).19-24 (IV)G. Use of passive disinfection caps containing disinfect- ing agents (eg, isopropyl alcohol) has been shown to reduce intraluminal microbial contamination and reduce the rates of central line-associated blood- stream infection (CLABSI). Use of disinfection caps on peripheral catheters has limited evidence but should be considered.
1. The length of exposure time to be effective depends upon product design; consult manufac- turers directions for use.18 (V)
2. Once removed, these used caps are discarded and are never reattached to the needleless connector.3,18 (II)
3. After removal, multiple accesses of the VAD may be required to administer a medication (eg, flush syringes and administration sets) and require additional disinfection before each entry. Scrubbing time, technique, and agents for disin- fection of the needleless connector between sub- sequent connections are unknown due to a lack of research. Consider using a vigorous 5- to 15-second scrub time with each subsequent entry into the VAD, depending upon the needleless connector design.25-30 (Committee Consensus)
4. Use a stopcock or manifold with an integrated needleless connector rather than a solid cap due to contamination from personnel hands and the environment. Replace the stopcock with a needle- less connector as soon as clinically indicated.31-33 (III)
H. Change the needleless connector no more frequently than 96-hour intervals. Changing on a more fre- quent time interval adds no benefit and has been shown to increase the risk of CLABSI.
1. When used within a continuous infusion system, the needleless connector is changed when the primary administration set is changed (eg, 96 hours).
2. For peripheral catheters with dwell times longer than 96 hours, there are no studies on changing the attached needleless connector/extension set.
3. Additionally, the needleless connector should be changed in the following circumstances: if the needleless connector is removed for any reason; if there is residual blood or debris within the needleless connector; prior to drawing a sample
for blood culture from the VAD; upon contamination; per organizational policies, pro- cedures, and/or practice guidelines; or per the manufacturers directions for use (see Standard 49, Infection).7,34,35 (IV)
I. Ensure that disinfecting supplies are readily avail- able at the bedside to facilitate staff compliance with needleless connector disinfection.14,36 (V)Tim Spencer, DipAppSc, BHSc, IC Cert, RN , APRN, VA-BC
Global Vascular Access, LLCSent from my iPhone
> On Jul 1, 2018, at 15:55, Michael Wishart wrote:
>
> Hi Cath
>
> I still have not seen definitive evidence that equates hub scrubbing with chlorhexidine containing swabs as being more effective than just 70% alcohol swabs for prevention of line infections.
>
> The 2016 INS guidelines state:
>
> F. Perform a vigorous mechanical scrub for manual disinfection of the needleless connector prior to each VAD access and allow it to dry.
> 1. Acceptable disinfecting agents include 70% isopropyl alcohol, iodophors (ie, povidone-iodine), or >0.5% chlorhexidine in alcohol solution. 7,16 (II)
> 2. Length of contact time for scrubbing and drying depends on the design of the needleless connector and the properties of the disinfecting agent. For 70% isopropyl alcohol, reported scrub times range from 5 to 60 seconds with biocide activity occurring when the solution is wet and immediately after drying. More research is needed for other agents or combinations of agents due to conflicting reports regarding the optimal scrub time. 3,17,18 (II)
> 3. Use vigorous mechanical scrubbing methods even when disinfecting needleless connectors with antimicrobial properties (eg, silver coatings). 19-24 (IV)
> G. Use of passive disinfection caps containing disinfecting agents (eg, isopropyl alcohol) has been shown to reduce intraluminal microbial contamination and reduce the rates of central line-associated bloodstream
> infection (CLABSI). Use of disinfection caps on peripheral catheters has limited evidence but should be considered.
>
> I do agree that staff confusion is an issue, so one product should be selected and made available. But until I see credible evidence to support use of chlorhexidine containing swabs on hubs, I will continue to promote 70% alcohol scrub the hub.
>
> My opinion, anyway.
>
> Cheers
> Michael
>
> Michael Wishart, CICP-E
> Infection Control Coordinator
>
> A 627 Rode Road, Chermside QLD 4032
> P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
>
> P Please consider the environment before printing this email
>
>
>
>
> From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Catherine Wade
> Sent: Monday, 2 July 2018 8:36 AM
> To: AICALIST@AICALIST.ORG.AU
> Subject: Re: [ACIPC_Infexion_Connexion] Scrub the hub in routine clinical settings
>
> Hi All,
> Agree with Cath.
>
> Historically we stocked both 70% alcohol & the alcohol 2% CHG swabs / solution in clinical areas
> After reviewing & auditing accessing devices it became quite clear that staff were confused about what to scrub the hub with or for insertion of a PIVC etc.
> There was a lack of standardisation amongst staff about what product to use on which vascular access device when asked,
> More frighteningly, staff also often referred to swabs according to the colour of the packet not the antiseptic solution use the blue swabs / use the pink swabs / use the orange swabs.
> To further complicate things – the colours of the swab packets can change depending on the supplier of the product. & at one point the alcohol swabs were virtually the same colour as the CHG swabs.
> Chinese whispers were also a problem as some staff had heard about CHG sensitivity either in a journal, TV, Dr Google or at a conference & were taking it upon themselves & influencing others to use alcohol only which was not procedure.
>
> Using a risk management approach 1st rule of thumb Eliminate!
> The decision was made by the LHF to remove the alcohol swabs from all patient units & only stock alcohol CHG unless the clinical area identified a specific need for just alcohol swabs.
> The risk of infection due to staff not using the correct antisepsis solution to scrub the hub or insertion far out-weighs the sensitivity issue for CHG.
>
> Cheers
> Catherine Wade
>
> Clinical Nurse Consultant | Infection Prevention & Control (IPAC)
> Level 1 / 67 Holden Street, GOSFORD NSW 2250
> Tel: (02) 4320 2664 | Internal Ext: 92664 | Page: 18885
> Fax:(02) 4320 2874 | Internal Fax: 92874
> Catherine.Wade@health.nsw.gov.au or CCLHD-IPAC@health.nsw.gov.au
>
>
>
>
> From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Cathryn Murphy
> Sent: Friday, 29 June 2018 3:37 PM
> To: AICALIST@AICALIST.ORG.AU
> Subject: Re: Scrub the hub in routine clinical settings
>
> Dear Daniella
>
> I recently reviewed evidence and guidelines for best practice with vascular access devices. Below are the recommendations I made on based on the review and the supporting references.
>
> I have never understood Australias reluctance to adopt scrub the hub campaigns and lack of interest in routine use of protective IV caps. As a recently hospitalised and immunosuppressed patient I worried every time my line was accessed as there was nothing uniform in any of the accesses. There are now good Australian research papers showing risk with even simple peripheral vascular catheters. IVs are inserted very commonly making them one of the most frequent infection risks in acute care settings.
>
> With regard to CHG I also note a general reluctance to its use in Australia as evidenced by poor recommendations in the draft NHMRC IC Guidelines, questions raised previously on this discussion forum and at ACIPC meetings. Personally I disagree with Michaels earlier comment given that it is often a long time between accesses of IV lines and if oncovered they can easily become contaminated hence an agent containing alcohol and CHG is safe to use in non CHG-sensitive populations and it gives immediacy plus residual. As you would appreciate CHG has been used extensively in healthcare and domestic settings for decades. True CHG sensitivity is extremely rare. Anaphylaxis reports typically demonstrate multi-site simultaneous exposure to CHG ie surgical skin prep + use of CHG lubricant jelly + CHG impregnated CVC insertion. The NHMRCs recommendation that we keep risk registries of CHG containing products is salient as is the recommendation to take adequate histories from patients regarding sensitivities.
>
> In a recent report where he considered resistance Kampf argued that we should use CHG cautiously and perhaps even in a stewardship way. He was smart to recognise that there is no universal agreed definition of CHG-resistance and that the mechanisms are very different to antimicrobial resistance.
>
> I expect many will disagree with my views but I am very happy that CHG was used extensively to help prevent infection in my recent surgery and hospitalisation. I would have warmly welcomed the use of routine CHG & alcohol hub disinfection.
>
> Recommendations based on literature and guideline review.
>
> Care must be taken not to contaminate the lines when accessing lines and their administration sets.1,65,72
>
> A single patient use application of 70% alcohol alone1,73 or >0.5% chlorhexidine in 70% alcohol1,10,29,72 should be used70 for 529- 15 seconds1,10,73 and allowed to dry when decontaminating the catheter hub or injection ports prior to every access of the circuit. This includes every time an infusion set is added or removed, as well as administration of medication.10,65 Supplies for disinfecting should be kept at the bedside.1
>
> Use of disinfection caps on peripheral and central catheters should be considered.1,72
>
> 1. Gorski LA, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;39(1S):1-256.
> 10. Loveday HP, Wilson JA, Pratt RJ, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2014;86 Suppl 1:S1-70.
> 29. Marschall J, Mermel LA, Fakih M, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(7):753-771.
> 65. Society. AaNZIC. Central Line Insertion and Maintenance Guideline. 2012; http://www.anzics.com.au/Downloads/ANZICS_Insertion%26maintenance_guideline2012_04.pdf, 2017.
> 70. Ling ML, Apisarnthanarak A, Jaggi N, et al. APSIC guide for prevention of Central Line Associated Bloodstream Infections (CLABSI). Antimicrob Resist Infect Control Antimicrobial Resistance & Infection Control. 2016;5(1).
> 72. Nursing. RCo. Standards for infusion therapy. London.: Royal College of Nursing.; 2016.
> 73. (INICC). INICC. International Nosocomial Infection Control Consortium (INICC) Bundle to Prevent Central Line Associated Bloodstream Infections (CLAB) in Intensive Care Units (ICU): An International Perspective. Argentina.2017.
>
>
> Cath
>
> Cathryn Murphy RN B. Photog MPH CIC FAPIC FSHEA CICP-E PhD
> Chief Executive Officer & Creative Director
> Infection Control Plus Pty Ltd
> Adjunct Associate Professor
> Faculty of Health Sciences and Medicine, Bond University
> QLD, Australia
>
> E: Cath@infectioncontrolplus.com.au
> M: +61 428 154154
> W:http://www.infectioncontrolplus.com.au
>
>
>
>
> From: ACIPC Infexion Connexion On Behalf Of Karanfilovska, Daniela
> Sent: Friday, 29 June 2018 10:25
> To: AICALIST@AICALIST.ORG.AU
> Subject: Scrub the hub in routine clinical settings
>
> Dear colleagues,
>
> I am interested to know if Australian hospitals are routinely using wipes containing chlorhexidine 2% with alcohol 70% to disinfect vascular access hubs (i.e. to scrub the hub). In particular, is this practised on general wards when accessing a PIVC?
>
> Many thanks,
> Daniela
>
> Daniela Karanfilovska
> Clinical Nurse Consultant
> Infection Prevention & Healthcare Epidemiology
>
> t 03 90762819 m 0427 703 769
> e D.Karanfilovska@alfred.org.au
>
> Alfred Health
> 55 Commercial Road
> Melbourne VIC 3004
> PO Box 315 Prahran
> VIC 3181 Australia
>
> Alfred Health incorporates The Alfred, Caulfield Hospital, Sandringham Hospital and Melbourne Sexual Health Centre
> http://www.alfredhealth.org.au
>
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Hello everyone
Really Interesting, relevant & important – can I put my thoughts into this very worthy discussion !!
I have had experience in my time as an ICP with similar issue as Cath W with the confusion with CHG and ETOH swabs looking so so similar and did have one area have an adverse event whereby a CHG swab was accidently selected and used to wipe a bung for IV access on Pt with severe known CHG allergy – requiring a MET call & ICU admission
So as result staff an management became anxious about having any opportunity for leaving any pt safety error margin given the swabs looked so similar & mistakes do / did happen and CHG allergy although touted as rare is real & scary for all concerned particular the pt and needs to be considered as part of what we direct staff to do / use
I agree with everyone that BSI’s linked to devices is a problem that we really need to tackle and keep actions relevant, timely ,simple & accountable for our staff / colleagues who can often deal with devices multiple times in a day in amongst many things when providing their pt care
So in reading up about what should be made available (one or the other – yes ,Eliminate!! ) so we had a look at information
currently NSW the update 2017 ACI CVAD policy and current NSW PIVC Guidelines 2017 -013 indicate that either
Chlorhexidine with alcohol or alcohol or povidine iodine.http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2013_013.pdf
some recent publications I came across are also interesting
I full heartedly agree with both Cathryn’s that the actual effectiveness of cleaning and drying times before staff accesses is often missed but really is so important so In reading a few articles they reiterate this seems to also be the greatest risk, i.e not what you use but how you use it.I have attached a recent letter to the editor in which the summary reiterates that these thoughts and that studies on CHG/ ETOH vs ETOH needed more research to really prove superiority
The other article I found really useful/ interesting in looking at how we support staff to best reduce risk of device related BSI and that was to provide hub cleaning & drying time . Interestingly the hub which required the least drying tie after cleaning was the ETOH swab
After the 15-second scrub was completed with 70% isopropyl alcohol, the NC was consistently dry after 5 seconds (Table 2); with 70% isopropyl and 2% CHG scrub, the NC was consistently dry after 20 seconds. The NC scrubbed with 10% povidone-iodine did not have a drying time established: it remained wet at 6 minutes
so we figured the empathise really needed to be on cleaning and drying times and given nurses are often running to catch up with their workload…. it was interesting to see that if we focused on education, training & information around effectively clean and drying that this was likely more in keeping with their work flow practices and priorities (work smarter not harder)
Given the risks to exposing patients to additional chlorhexidine after the adverse event , the literature re cleaning and drying times being the priority etc we made the decision to go with alcohol swabs & more information education re bung cleaning.
The product has been changed over (CGH swabs are available in a stick form for skin prep such as PIVC insertions & BC collections etc …so there can be no mix up ) the education is still filtering through & perhaps need more emphasis but the recent information attached has been most helpful to forward onto our educators and end users who still think it about what you use not how you use …
I leave the floor open for any interesting comments or useful feedback on what others may be finding that is different …… as I indicated devices related BSI are not OK
Have a great day everyone – happy Monday
Regards
Lindy
Lindy Ryan
District Infection Prevention & Control CNC | Clinical Governance Unit MNCLHD
Level 1 Coffs Specialist Centre, Pacific Hwy, Coffs Harbour
Mob 0419 990 693 | lindy.ryan@ncahs.health.nsw.gov.au
http://www.health.nsw.gov.au[http://internal.health.nsw.gov.au/communications/e-signatures/images/NSW-Health-Mid-North-Coast-LHD.jpg]
“Wise and humane management of the patient is the best safeguard against infection”
(Florence Nightingale Circa 1860)Hi All,
Agree with Cath.Historically we stocked both 70% alcohol & the alcohol 2% CHG swabs / solution in clinical areas
After reviewing & auditing accessing devices it became quite clear that staff were confused about what to scrub the hub with or for insertion of a PIVC etc.
There was a lack of standardisation amongst staff about what product to use on which vascular access device when asked,
More frighteningly, staff also often referred to swabs according to the colour of the packet not the antiseptic solution – ‘use the blue swabs’ / ‘use the pink swabs’ / ‘use the orange swabs’.
To further complicate things – the colours of the swab packets can change depending on the supplier of the product. & at one point the alcohol swabs were virtually the same colour as the CHG swabs.
Chinese whispers were also a problem as some staff had heard about CHG sensitivity either in a journal, TV, Dr Google or at a conference & were taking it upon themselves & influencing others to use alcohol only which was not procedure.Using a risk management approach – 1st rule of thumb Eliminate!
The decision was made by the LHF to remove the alcohol swabs from all patient units & only stock alcohol CHG unless the clinical area identified a specific need for just alcohol swabs.
The risk of infection due to staff not using the correct antisepsis solution to scrub the hub or insertion far out-weighs the sensitivity issue for CHG.Cheers
Catherine WadeClinical Nurse Consultant | Infection Prevention & Control (IPAC)
Level 1 / 67 Holden Street, GOSFORD NSW 2250
Fax:(02) 4320 2874 | Internal Fax: 92874
Catherine.Wade@health.nsw.gov.au or CCLHD-IPAC@health.nsw.gov.au[http://internal.health.nsw.gov.au/communications/e-signatures/images/NSW-Health-Central-Coast-LHD.jpg]
Dear Daniella
I recently reviewed evidence and guidelines for best practice with vascular access devices. Below are the recommendations I made on based on the review and the supporting references.
I have never understood Australia’s reluctance to adopt scrub the hub campaigns and lack of interest in routine use of protective IV caps. As a recently hospitalised and immunosuppressed patient I worried every time my line was accessed as there was nothing uniform in any of the accesses. There are now good Australian research papers showing risk with even simple peripheral vascular catheters. IVs are inserted very commonly making them one of the most frequent infection risks in acute care settings.
With regard to CHG I also note a general reluctance to its use in Australia as evidenced by poor recommendations in the draft NHMRC IC Guidelines, questions raised previously on this discussion forum and at ACIPC meetings. Personally I disagree with Michael’s earlier comment given that it is often a long time between accesses of IV lines and if oncovered they can easily become contaminated hence an agent containing alcohol and CHG is safe to use in non CHG-sensitive populations and it gives immediacy plus residual. As you would appreciate CHG has been used extensively in healthcare and domestic settings for decades. True CHG sensitivity is extremely rare. Anaphylaxis reports typically demonstrate multi-site simultaneous exposure to CHG ie surgical skin prep + use of CHG lubricant jelly + CHG impregnated CVC insertion. The NHMRC’s recommendation that we keep risk registries of CHG containing products is salient as is the recommendation to take adequate histories from patients regarding sensitivities.
In a recent report where he considered “resistance” Kampf argued that we should use CHG cautiously and perhaps even in a stewardship way. He was smart to recognise that there is no universal agreed definition of CHG-resistance and that the mechanisms are very different to antimicrobial resistance.
I expect many will disagree with my views but I am very happy that CHG was used extensively to help prevent infection in my recent surgery and hospitalisation. I would have warmly welcomed the use of routine CHG & alcohol hub disinfection.
Recommendations based on literature and guideline review.
Care must be taken not to contaminate the lines when accessing lines and their administration sets.1,65,72
A single patient use application of 70% alcohol alone1,73 or >0.5% chlorhexidine in 70% alcohol1,10,29,72 should be used70 for 529- 15 seconds1,10,73 and allowed to dry when decontaminating the catheter hub or injection ports prior to every access of the circuit. This includes every time an infusion set is added or removed, as well as administration of medication.10,65 Supplies for disinfecting should be kept at the bedside.1
Use of disinfection caps on peripheral and central catheters should be considered.1,72
1. Gorski LA, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;39(1S):1-256.
10. Loveday HP, Wilson JA, Pratt RJ, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2014;86 Suppl 1:S1-70.
29. Marschall J, Mermel LA, Fakih M, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(7):753-771.
65. Society. AaNZIC. Central Line Insertion and Maintenance Guideline. 2012; http://www.anzics.com.au/Downloads/ANZICS_Insertion%26maintenance_guideline2012_04.pdf, 2017.
70. Ling ML, Apisarnthanarak A, Jaggi N, et al. APSIC guide for prevention of Central Line Associated Bloodstream Infections (CLABSI). Antimicrob Resist Infect Control Antimicrobial Resistance & Infection Control. 2016;5(1).
72. Nursing. RCo. Standards for infusion therapy. London.: Royal College of Nursing.; 2016.
73. (INICC). INICC. International Nosocomial Infection Control Consortium (INICC) Bundle to Prevent Central Line Associated Bloodstream Infections (CLAB) in Intensive Care Units (ICU): An International Perspective. Argentina.2017.
Cath
Cathryn Murphy RN B. Photog MPH CIC FAPIC FSHEA CICP-E PhD
Chief Executive Officer & Creative Director
Infection Control Plus Pty Ltd
Adjunct Associate Professor
Faculty of Health Sciences and Medicine, Bond University
QLD, AustraliaE: Cath@infectioncontrolplus.com.au
M: +61 428 154154
W:http://www.infectioncontrolplus.com.auDear colleagues,
I am interested to know if Australian hospitals are routinely using wipes containing chlorhexidine 2% with alcohol 70% to disinfect vascular access hubs (i.e. to ‘scrub the hub’). In particular, is this practised on general wards when accessing a PIVC?
Many thanks,
DanielaDaniela Karanfilovska
Clinical Nurse Consultant
Infection Prevention & Healthcare Epidemiologyt 03 90762819 m 0427 703 769
e D.Karanfilovska@alfred.org.auAlfred Health
55 Commercial Road
Melbourne VIC 3004
PO Box 315 Prahran
VIC 3181 Australia
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Alfred Health incorporates The Alfred, Caulfield Hospital, Sandringham Hospital and Melbourne Sexual Health Centre
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