[James Rippey]

Hi Kate,
We use safety needles.
As clinicians the main issue is they are shorter and more awkward to use. The hinged safety mechanism uses up some of the shaft and provides a bump on the edge at the needle base.
Most of the time we can work around the issue but we all know how to efficiently break off the safety mechanism when we require an unencumbered needle for slightly more complex procedures where fine control and length are important.
We also have a secret store of non-safety needles if absolutely required.
It is a careful balance between imposing appropriate safety mechanisms for the majority of cases and providing a system that doesnt interfere with occasional delicate procedures.
These work arounds are what happens in the real world. Inevitable.
Good luck and Happy Christmas.
James Rippey
Emergency Physician

Sent from my iPhone

> On 21 Dec 2017, at 5:53 am, Michelle Callard wrote:
>
> Hi Cate,
> We have rolled out safety needles throughout our 2 sites for sub cut and IM needles. I am happy to discuss brands offline and reasons why they were chosen.
> Merry Christmas and happy New Year
>
> Regards
>
> Michelle Callard
> CNC Infection Prevention
> Camden and Campbelltown Hospitals
> Campbelltown Hospital
> Therry Rd, Campbelltown, NSW 2560
>
> T: (02) 46343788
> Mob: 0407951631
> Fax: (02) 46343790
>
> Never Miss a Moment
>
>
>
>
>
>
>
> From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Cate Coffey
> Sent: Wednesday, 20 December 2017 3:33 PM
> To: AICALIST@AICALIST.ORG.AU
> Subject: Safety Needles
>
> Hi everyone,
> Can you tell me if your facilities use safety needles in ED and if so has there been any issues brought to your attention?
> Thanks and Merry Christmas.
>
>
> Cate Coffey | Clinical Nurse Consultant
> Infection Prevention and Control Unit | Central Australia Health Service
> Northern Territory Government
> Alice Springs Hopsital, Gap Rd, Alice Springs
> GPO Box 2234, Suburb, NT Postcode
> p … 08 89517737
> e … cate.coffey@nt.gov.au http://www.nt.gov.au/health
>
> Our Vision: Better health outcomes for all Central Australians
> Our Values: Community at the Centre | Equity and Integrity | We are Accountable | We are Relevant Today and Ready for Tomorrow | We are Committed to High Quality Care | We Value our Partnerships
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[James Rippey]

Dear Gemma,

There will be a very heterogenous response from the Emergency Departments
in this area.

We use a video-laryngoscope (C-Mac) as the laryngoscope of choice. It is
not single use and is processed by CSSD between each use.
It is sent to CSSD with a patient sticker so records can be maintained.

As a second option we rarely use the standard MacIntosh or Miller blades
and these too are processed by CSSD.

My colleagues decided the “feel” of single use disposable blades was not
adequate – despite the far more reliable and bright light source. I plan to
revisit this as an option in the near future.

James

On Fri, Nov 10, 2017 at 11:03 AM, Klintworth, Gemma wrote:

> Hi all,
>
>
>
> We are interested to know how other organisations are managing their
> laryngoscope blades. This is something that we are currently looking at.
>
>
>
> A couple of questions;
>
>
>
> Firstly, are most organisations using disposable or reprocessable blades?
> Secondly, if you are reprocessing blades, are you able to track them to a
> patient i.e. do clinicians put the sticker in the notes?
>
>
>
> And finally, particularly for resus areas, do you find that clinicians
> leave blade packets open in order to check the lights regularly? How are
> you managing this as a contamination risk?
>
>
>
> Thank you,
>
>
>
> Gemma
>
>
>
> *Gemma Klintworth*
> Senior Infection Prevention Nurse Consultant
>
> Accredited Nurse Immuniser
>
> CIPC-E
>
> Infection Prevention and Healthcare Epidemiology
>
> *e* G.Klintworth@alfred.org.au
>
> *m* 0439 582 107
>
> *t* 03 9076 3139
>
> *Alfred Health*
> 55 Commercial Road
>
> Melbourne VIC 3004
>
> PO Box 315 Prahran
> VIC 3181 Australia
>
> Alfred Health incorporates The Alfred, Caulfield Hospital and Sandringham
> Hospital
> http://www.alfredhealth.org.au
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—
*James Rippey*
Emergency Physician
Sir Charles Gairdner Hospital

Mobile 0400990186

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[James Rippey]

Dear Tara,

I’m one of the those dastardly Emergency physicians!

We live and work in a high stress, extremely high patient throughput
environment.
We strongly believe in evidence based practice and improving things for our
patients.
You are correct, most of the peripheral IV lines we place are not done in
time critical life threatening situations.

There is no doubt the focus of recent years on improving HH and ANTT has
had a positive infection control impact in our environment.

My suggestions:

*Ensure following the “rules” is easy.*
An IV trolley with all the equipment on it, always well stocked.
There must be enough IV trolleys for your department (a ratio of 1 trolley
per 3 ED bays seems to work).
The top should be clear so a dressing pack can be opened onto it.
Must have sharps bin attached… all the usual stuff.
Lots of sinks, appropriate hand cleaning stuff – all within ?10 steps of
any patient cubicle.

*Try and get and then present some absolutely relevant evidence for your
institution.*
Take photos / get results of some of the many infections we are supposedly
causing – and show us.
You won’t need many to sway opinion, and you don’t even need to demonstrate
our performance is worse than others.
You know what they say about one picture!
Don’t make it seem punitive, make sure it’s educational and supportive. We
get enough confrontation in ED.

*Get senior medical ED buy in.*
Is there an ultrasound machine in your ED?
Who is in charge of that?
That person is usually the person to approach – because finding a blood /
gel covered probe (which used to happen frequently) is what inspired my
enthusiasm to improve things.
Last week I was emailed asking why the department is now using so many
sterile probe covers…

*Make sure the medical staff know what is best practice – and standardise
it please!*
We get new doctors every 3 months. Orientation must cover a lot.
Infection control advice regarding PIVC placement is different in our
metropolitan tertiary EDs – no wonder our doctors are confused.
In one we use must sterile gloves (presumably anticipating we will palpate
the vein after the chlorhexidine dries), in the other we get in trouble if
we use sterile gloves (because they are too expensive; and anticipating we
will not palpate the vein).
A single laminated A4 page with key points is worthwhile. Put it on the
trolleys.

*Audit and wrist slapping is a negative experience,* and when our focus is
on making difficult diagnoses and meeting time related targets, and often
arguing with inpatient specialties it doesn’t help.
Gentle frequent education and demonstration would be a far better approach
in my opinion – send someone down to work with the junior doctors at the
beginning of each rotation for a couple of days.
One IV each with an infection control person showing them one on one what
to do and why will shape their practice forever.

*With central lines there should be absolutely no room for variation.*
Get an ICU consultant to come down and explain how they want us to do it.
Touch on the evidence which is strong in this arena.
The ICU consultants have our respect. They put in lots of CVCs, and most
patients with central lines to to ICU. We will listen because none wants a
line they’ve put in removed just because it may have been put in using
suboptimal technique.
We should also document clearly whether the line was put in in a true
emergency situation or whether it was a controlled situation – so good
decisions regarding CVC replacement can be made.

Just thoughts.

All the best

James Rippey

On Mon, Mar 21, 2016 at 11:49 AM, Anderson, Tara L (THS) wrote:

> Hi all
>
>
>
> *I wondered if I could ask others what their expectation and experiences
> have been with enhancing hand hygiene and aseptic non-touch technique
> (ANTT) practice within their Emergency Departments, particularly amongst
> medical staff?*
>
>
>
> The HH compliance of the medical staff within our Emergency
> Department when last audited was 41%. This is in contrast to the overall HH
> compliance of >70% for medical staff in our hospital. It is also in
> contrast to the HH compliance of 70% amongst the nursing staff within the
> Emergency Department.
>
>
>
> In relation to ANTT practice, we have undertaken observations
> within the Emergency Department, and there was suboptimal ANTT practice,
> particularly amongst medical staff in relation to procedures; this related
> to a number of components including the following:
>
>
>
> Hand hygiene was undertaken but not at the appropriate
> times/moments within the procedure
>
> Inappropriate glove use e.g. donning of gloves with multiple
> contacts within the external environment, sterile equipment and the patient
>
> A work surface was not always cleaned (before or after)
>
> Equipment often gathered piece-meal over protracted time period
>
> The field was not always clearly defined nor dedicated to the
> procedure
>
> Packaged equipment were handled in manner that would increase
> the risk of contamination e.g. equipment placed onto patients bed,
> equipment placed onto shared bench
>
> Key parts were not always protected during the procedures
>
>
>
> We have had difficulty impressing on the senior medical staff within the
> Emergency Department the importance of optimal HH and ANTT practice in all
> clinical settings including within the Emergency Department.
>
>
>
> Today I have been informed that no-one is doing anything like ANTT in
> emergency environments; this was the impression obtained after their
> attendance at a Patient Safety Course during the last week with a large
> number of ED Directors and Senior ED Nursing Staff from around Australia.
>
>
>
> I understand that practice may need to be modified in an emergency
> situation within the Emergency Department but much of the patient contact
> within this clinical area, does not seem be related to emergency care.
> It is my understanding that the expectation should still be that hand
> hygiene and ANTT practice be undertaken within the ACSQHC framework
> regardless of where your patient is situated including the Emergency
> Department.
>
>
>
> *I wondered if others could share their thoughts and experiences with me?*
>
>
>
> Should we be expecting HH and ANTT to be practiced within the
> Emergency Department similar to other clinical areas within the hospital?
>
>
>
> Has the ANTT program in your facility excluded the Emergency
> Department? If so, why? Has it been adapted or modified for this clinical
> area?
>
>
>
> Thanks for your input and assistance in addressing this issue.
>
>
>
> Tara
>
> *Tara Anderson*
>
> Infectious Diseases Physician and Microbiologist
> Medical Advisor, Infection Prevention and Control, RHH
>
> 03 61667449 (direct)
> 03 61667391 (fax)
> 0417 561595 (mobile)
>
>
>
>
>
>
>
> ——————————
>
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—
*James Rippey*
Emergency Physician
Sir Charles Gairdner Hospital
King Edward Memorial Hospital for Women

Mobile 0400990186

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[James Rippey]

Hi Michael,

No, that little gem hasn’t raised it’s head.
Something to look forward to!

Cheers
James

On Wed, Dec 17, 2014 at 11:48 AM, Michael Wishart wrote:
>
> James, interestingly today on the APIC (US infection prevention
> professional group) discussion list the question was asked about
> pre-processing trans-vaginal probes prior to use if not used within 12
> hours (like we require for fibreoptic endoscopes).
>
>
>
> Has there been any discussion in Australia about that kind of requirement
> as well? Just something else to consider.
>
>
>
> Cheers
>
> Michael
>
>
>
>
>
> *Michael Wishart*
>
> 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
> [image: cid:image001.png@01D01926.61F1C2B0]
> P *Please consider the environment before printing this email*
>
>
>
> *From:* ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] *On
> Behalf Of *James Rippey
> *Sent:* Wednesday, 17 December 2014 12:52 PM
> *To:* AICALIST@AICALIST.ORG.AU
> *Subject:* Ultrasound probe cleaning
>
>
>
> Dear Team,
>
>
>
> I am a member of the Standards of Practice Committee for the Australasian
> Society for Ultrasound in Medicine.
>
>
>
> There remains a great deal of heterogeneity in recommendations regarding
> cleaning of ultrasound transducers, and conflicting recommendations by
> various bodies. We also receive pressure from vendors to support their
> products, usually backed by a host of complicated and difficult to
> interpret evidence.
>
>
>
> I wondered whether you had specific up to date evidence based references
> you would recommend us reviewing regarding:
>
>
>
> 1. Regular cleaning of ultrasound transducers used on closed skin.
>
>
>
> 2. Cleaning of transducers used for intracavity scanning.
>
>
>
> For those of you wishing to read further:
>
>
>
> Currently most ultrasound users are aware they should perform:
>
>
>
> 1. Regular cleaning of ultrasound transducers used on closed skin.
>
> – Clean as you would your hands – wash with warm mild detergent and
> running water between each patient.
> – Some would use Chlorhexidine wash or alcohol impregnated wipes –
> although these are not recommended by manufacturers as they may damage the
> face of the transducer.
> – Where there is contact with body fluids clean as per intracavity
> transducer.
>
> 2. Cleaning of intracavity transducers – high level disinfection
>
> – Wash removing all visible gel / residue – running water, mild
> detergent, wipe dry.
> – Use one of the approved agents according to manufacturer guidelines
> – Including hydrogen peroxide, glutaraldehyde, ortho-phthalaldehyde
> (OPA)
> – Opinion on chlorine dioxide delivered via the wipe system, and
> paracetic acid seems divided.
> – The concern regarding the wipes is based on inter user variability.
> – There has been some literature describing paracetic acid damage to
> endoscopes.
>
> Your advice is again much appreciated.
>
> Just want to ensure we remain up to date.
>
>
>
> Sincerely
>
> James Rippey
>
>
>
> —
>
> *Associate Professor James Rippey*
>
>
>
> Emergency Physician
>
> University of Western Australia
>
> Sir Charles Gairdner Hospital
>
> King Edward Memorial Hospital for Women
>
> Emergency Medicine Lead for the Kimberley
>
>
>
> Mobile 0400990186
>
>
>
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—
*Associate Professor James Rippey*

University of Western Australia
Sir Charles Gairdner Hospital
King Edward Memorial Hospital for Women

Mobile 0400990186

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[James Rippey]

Thank you for your considered opinions regarding the best ultrasound medium.

My final solution:

1. Where there is a controlled situation I will use ultrasound gel but
minimise the quantity, make sure the needle doesn’t go through it, and wipe
it off afterwards with chlorhexidine soaked gauze, letting it dry again
before putting on the final dressing.

2. In the critically ill patient (sometimes we are getting central access
whilst CPR is in process) I will use chlorhexidine as the medium. I cannot
afford to have trouble advancing the wire because it has gel on it (or my
gloved fingers) in these situations.

All the best
James Rippey

On Thu, Aug 8, 2013 at 7:25 AM, Tim Spencer
wrote:

> Hi James,
> Good question.
> To answer your question about best conducting medium, sterile ultrasound
> gel is the BEST conducting medium for transmission of image from the skin.
> It is designed specifically for that purpose.
>
> 1. I have been using US for VA for almost 10years now and I always use
> sterile gel – I have not had an issue of the gel smudging the CHG on the
> skin, as it well dried before I put needle to skin.
> A handy tip I perform that you might be interested in trying is once you
> have located your insertion point for puncture, with the probe in place,
> gently wipe down the edge of the probe against the skin to remove any
> excess gel that bulges out from under the probe. This reduces the risk of
> getting gel in the tip of the needle (which reduces your flashback
> indicator also).
>
> 2. Sterile saline isn’t a great conductor for image transmission.
>
> 3. Wet CHG is at risk of entering through the puncture site of the skin,
> and although a very small amount, the risk of CHG reaction is increased.
>
> If the CHG and IPA has completely dried on the skins surface, I find that
> is not removed when wiping the gel. But I also don’t need a lot of gel
> usually, just enough to get a clear image of the vessel.
> I would send an image, but are unable to do so on this listserver.
>
> Alternatively, you could reapply your CHG/IPA after cleaning the area to
> remove blood/gel, etc and put a fresh layer of CHG prior to the dressing
> application.
>
> 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
>
>
> —–Original Message—–
> From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On
> Behalf Of James Rippey
> Sent: Wednesday, 7 August 2013 5:58 PM
> To: AICALIST@AICALIST.ORG.AU
> Subject: Ultrasound guided vascular access question
>
> Dear Wise Anti-Infection Folk,
>
> When performing vascular access using ultrasound guidance we use standard
> aseptic technique with 2% chlorhexidine for the skin, and sterile
> ultrasound probe cover.
>
> Between the skin with dried chlorhexidine, and the probe cover we need an
> ultrasound conducting medium.
>
> My question relates to what is the best sound conducting medium.
>
> Options are:
>
> 1. Sterile ultrasound gel.
> Putting the needle through gel into the patient bothers me, and the gel
> makes things slippery and awkward if needing to advance a wire for the
> Seldinger technique. Also wiping the gel off afterwards so a dressing will
> stick removes the chlorhexidine.
>
> 2. Sterile saline.
> Works well, isn’t slippery, but washes away the chlorhexidine.
>
> 3. More chlorhexidine.
> Works well, isn’t slippery, but means we put a needle through wet
> chlorhexidine into the patient.
>
> I anticipate the amount of chlorhexidine introduced if we go through wet
> chlorhexidine with a needle is miniscule, and this is probably the best
> option, but seek your advice.
>
> Many thanks in anticipation.
>
> James Rippey
>
> MBBS DDU DCH FACEM
> Specialist in Emergency Medicine
> Sub specialty Emergency Ultrasound
>
> Associate Professor
> University of Western Australia
> Sir Charles Gairdner Hospital &
> King Edward Memorial Hospital for Women
>
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> Sydney & South Western Sydney Local Health Districts regularly monitor
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> Messages posted to this list are solely the opinion of the authors, and do
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—
*Associate Professor James Rippey*

University of Western Australia
Sir Charles Gairdner Hospital
King Edward Memorial Hospital for Women

Mobile 0400990186

Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.

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