EBP in the ER

[Belle2013]

I am brainstorming for an EBP Project in the ER. I have some ideas including Chlorhexidine wipes for vs alcohol when accessing an IV port, ways to reduce hemolyzing blood specimens, etc but I wanted to get some input from you all on all nurses. Are there some topics you think about in your ER and say why do we do it that way or which way is better? I want to research something that is going to make a difference and not overdue something that's been done a thousand times! Any input would be great!

[emtb2rn, BSN, RN, EMT-B]

Check the ENA site, they publish research monthly that relates specifically to the ER. You can also check Google Scholar.

Chlorex is superior to alcohol for one very important reason - BAL.

[BrooklynRN11201]

not sure if this is helpful, but I use Chlorhexidine to cleanse, I let it dry, and then I use alcohol before insertion since it's easier to feel the vein with alcohol, your finger slides over it better. just my .02

[iluvivt, BSN, RN]

CHG if used for skin antisepsis for IV insertion site preparation should be allowed to air dry and then isopropyl alcohol (IPA)should not then be used on top of that. The CHG persists on the skin (continues to work) for 6 hours after application so it should not be wiped off with 2 x 2 s or alcohol. A "no touch" technique is the current standard so once prepped the site should not be touched unless you slide on a sterile glove on the hand you have trained to touch with..your dominate hand can still have on a non sterile glove. If you do not touch the site again regular exam gloves are just fine. IPA (alcohol) remains a choice for site preparation as well but requires friction and a longer scrub time . Best to pick one or the other or follow your policy and use it per the current recommendation but CHG is the preferred choice per CDC,INS and IHI!. Adequate skin contact and drying time are critical to minimize risk of infection.

In terms of using CHG vs IPA for prior to access of an IV port current recommendation based on evidence shows that IPA is just as effective and cheaper and thus one of the reasons for the emergence of products such as Curos port covers. Also some CHG products IFUS are for skin preparation use ONLY so need to check before use.

[dansamy]

I hate chg because it makes the skin tacky. My introcaths seem to "hang" or tug. And feeling the vein is sometimes necessary to successful cannulation.

I typically use ipa & label my iv for a 3 day site change versus a 4 day for chg.

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Here are a couple of possible topics:

1) Drawing a single set of cultures rather than x2... We generally did single cultures at my last job and the rate of contamination was very low.

2) Use of IPA caps on all line ports... don't need to clean them prior to access. Their use has been correlated to significantly lower rates of BSIs.

[iluvivt, BSN, RN]

Not necessary to label the site for a more frequent change if you use IPA instead of CHI for skin antisepsis.You also need to consider vein preservation.The recommendations have changed for routine site rotation.The new recommendation is to change PIV sites based on assessment.I will post them later from my home computer.You might want to try cleansing the skin with the IPA first then the CHG The introcan tends to be a bit dull when computer to the insyte so good traction in a downward fashion can also help.

[dansamy]

My facility's policy dictates that sites cleaned with ipa get changed after 3 days, chg after 4 days. We can override that with an MD order to leave in place as long as it is patent & not reddened/leaking.

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[turnforthenurse, MSN, NP]

1) Drawing a single set of cultures rather than x2... We generally did single cultures at my last job and the rate of contamination was very low.

Interesting, because I thought the purpose of drawing 2 sets was in case of contamination in one set...

[iluvivt, BSN, RN]

http://www.ins1.org/files/public/07_05_12_Assessment_Position_Paper_BOD_FINAL.pdf

Take a look..for sure follow your policy but always a good idea to keep up,make suggestions and know what the standard of care is and what the research shows since you will be held to that standard in a court of law. There is no clinical benefit to to changing the site at 3 vs 4 days based on the antiseptic used..better to base on clinical assessment of of the site. Think about it..when you change the site you again have to break the skin that has resident and not resident bacteria on it that can be introduced into a patient's system. The CHG that was used to scrub the skin has long since stopped working as has the IPA so at that point to protect the pt the IV pathways (caps-Ysites-etc) must be scrubbed and protected.