What is intermittent tubing and how often do you change it?

  1. 2 This is a recurrent debate where I work and it's come up again so I'm looking for how this is generally interpreted:

    The first disagreement is about how do we define "intermittent" tubing. Is it tubing that is infusing intermittently or tubing that is connected intermittently.

    If we define it by being intermittently connected, do we say that all disconnections make the tubing "intermittent", or is it just when tubing is disconnected for periods between medications and is left unattended. And depending on that answer, how often is it changed.

    I'd be quite happy with just answers to these questions, but if anyone can support their policies with evidence or rationale then that's bonus points. (Yes, we've tried to clarify this with the INS with no response for many years).
  2. Visit  MunoRN profile page

    About MunoRN

    MunoRN has '9' year(s) of experience. From '.'; Joined Nov '10; Posts: 6,071; Likes: 12,773.

    12 Comments so far...

  3. Visit  jadelpn profile page
    0
    Our current policy is that IF it is a dedicated line for fluids, it is changed q 3 days, along with when an IV would be rotated.
    If it is a central line, it would still be q 3 days. This is a link regarding the safety of even more than 3 days to 7 days.

    Optimal frequency of changing ... [Infect Control Hosp Epidemiol. 2001] - PubMed - NCBI

    The rationale is that if you are rotating an IV, there should be fresh tubing as well.

    The tubing that is used to infuse something else--anything else but fluids (IV antibiotics, solumedrol, that type of thing) is q 24 hours. The rationale behind this is that it is a situation where you are putting on and taking off the tubing at least once, if not more than that over the various infusion times. Most of the time, these are secondary lines, however, even if a primary it is q 24 hours. Otherwise, it could introduce infection.

    For blood products, the entire lot is taken down with new everything put up for any other blood products given, as our policy is 4 hours.
  4. Visit  classicdame profile page
    0
    look on the package for the manufacturer's recommendations. We change q 72 hours and policy is to onever cross-contaminate (once an electolyte is infusing that is all that should go thru, no additives). BLood tubing has to be changed every four hours, which usually means every unit if PRBC
  5. Visit  blondy2061h profile page
    2
    Our policy is tubing gets changed every 4 days whether its in use constantly or occasionally disconnected. Tubing not in use gets capped with an alcohol cap.
    BSNbeDONE and KelRN215 like this.
  6. Visit  Esme12 profile page
    7
    Once an IV has been disconnected it is no longer considered a closed system and therefore is treated as all intermittent lines.

    According to the Infusion Nursing Standards of Practice, a secondary or piggyback set should remain connected to the primary continuous set. If this happens, the entire system can be changed together no more frequently than 96 hours. Connecting and disconnecting these piggyback sets puts these in the intermittent set category and they should be changed every 24 hours.

    All studies on sets have either purposefully omitted data on these piggyback sets or not provided information about them at all. Therefore there is no "real" evidence about length of use.

    All sets used intermittently, being connected and reconnected with each dose should be changed by 24 hours as this was the original time established for use of all sets. Extending beyond this period has not been shown to be safe.

    These are the CDC guidelines.....http://www.cdc.gov/hicpac/bsi/07-bsi...mles-2011.html
    canigraduate, GrnTea, maydaysvp, and 4 others like this.
  7. Visit  MunoRN profile page
    0
    Quote from jadelpn
    Our current policy is that IF it is a dedicated line for fluids, it is changed q 3 days, along with when an IV would be rotated.
    If it is a central line, it would still be q 3 days. This is a link regarding the safety of even more than 3 days to 7 days.

    Optimal frequency of changing ... [Infect Control Hosp Epidemiol. 2001] - PubMed - NCBI

    The rationale is that if you are rotating an IV, there should be fresh tubing as well.
    I think it's 96 hours minimum now.

    Quote from jadelpn
    The tubing that is used to infuse something else--anything else but fluids (IV antibiotics, solumedrol, that type of thing) is q 24 hours. The rationale behind this is that it is a situation where you are putting on and taking off the tubing at least once, if not more than that over the various infusion times. Most of the time, these are secondary lines, however, even if a primary it is q 24 hours. Otherwise, it could introduce infection.

    For blood products, the entire lot is taken down with new everything put up for any other blood products given, as our policy is 4 hours.
    I've heard a lot of interpretations of the INS standards but not that one yet. My first question would be why is the secondary tubing being disconnected, or is it. Do you change all lines carrying medications every 24 hours, even if they are continuously infusing and continuously connected?
  8. Visit  MunoRN profile page
    0
    There's a couple of arguments that come up which there don't seem to be answers to. The basic premise of administration set maintenance is that the potential to introduce bacteria should be minimized. This is why disconnections/connections of the set should be minimized, we know from studies that changing tubing also presents a risk of introducing bacteria. Changing sets every 24 hours carries 4 times as much risk of introducing bacteria as does changing every 96 hours, changing tubing doesn't remove the bacteria introduced during the last tubing change, it just adds to it. In some fluids (lipids, blood, etc) the bacteria introduced can proliferate and actually introduce more bacteria to the patient than what occurs with a tubing change, and therefore potentially justifies changing it more often. This isn't the case with common IV fluids however (although there is some debate about how much gram negative bacteria in D10 solutions).
  9. Visit  MunoRN profile page
    0
    Another argument is around what constitutes "intermittent". The studies used by the CDC specifically excluded intermittently infusing sets, antibiotics to be specific, many of their studies occurred in clinical settings and likely included numerous short term disconnections. Unfortunately, the INS and the CDC don't use the same definition of "intermittent tubing", and appears like the INS is referring to a CDC recommendation that doesn't actually exist.
  10. Visit  MunoRN profile page
    0
    Another argument is about when more frequent changes are justified, and aren't potentially more harmful than less frequent changes. The INS has clarified that changing an intermittent set at 24 hours shouldn't present the opportunity to introduce more bacteria than would have otherwise occurred because the set is already disconnected anyway when the new tubing is hung, however most of the tubing included in this definition is tubing that would otherwise not have needed to be disconnected and could have remained a closed system, changing the tubing at 24 hours from disconnection only offers an additional opportunity to introduce bacteria. For instance, let's say you need to removing a tubing set (a) as it is no longer being used. Another tubing set (b) is connected at the distal y-port that will continue to be used. So you disconnect (a), clean the cap and connect (b) directly to the cleaned cap. By INS definitions, (b) now needs to be changed in 24 hours, even if it's only been hanging for a few hours. There was certainly potential to introduce bacteria when removing tubing set (a) and connecting tubing set (b), but any bacteria introduced will infuse into the device or patient, and anything "stuck" in tubing can't proliferate enough to send more bacteria into the device or patient, so changing the set in 24 hours is unlikely to have any effect on the bacteria that may have been introduced, and actually it only creates the opportunity to introduce more bacteria.

    In other words, in that situation, re-designating a tubing as "intermittent" and changing it in 24 hours has only the potential to cause harm, and carries no potential benefit.
  11. Visit  Atlhonee profile page
    0
    Usually the policy is to change all IV tubing every 3 days regardless of intermittent or not with some exceptions. Of course if you are hanging TPN/Lipids it would be every 24 hours as well as with propofol. Central Lines I was always taught when you change the tubing you change the caps and vice versa. If I were you , I would resort to my policy and procedure manual....can't go wrong with that. If you still need clarification you can always go to your supervisor or even ask the pharmacy.
  12. Visit  jadelpn profile page
    1
    Quote from MunoRN
    I think it's 96 hours minimum now.



    I've heard a lot of interpretations of the INS standards but not that one yet. My first question would be why is the secondary tubing being disconnected, or is it. Do you change all lines carrying medications every 24 hours, even if they are continuously infusing and continuously connected?
    Yes. The secondary is disconnected from the primary fluids, and capped. Due to multiple secondary infusions over a period of time, or a practice issue to just have primary running--nurses will do it both ways (but I have also seen the primary "back up" into an empty secondary, this avoids the issue)And depending on pump, free flow...

    Either the tubing is primed and reused if it is within the 24 hour time period. All have to be labelled. And our policy is still 72 hours for fluids, as it coordinates with the IV rotation. And of course, it there's no fluids just IV infusions, then the primary is taken off and capped for reuse or a new set if after 24 hours, IV becomes a SL.

    I think the bottom line is the push to reduce/eliminate hospital acquired infections. When we were surveyed, there was checking of all IV sites that they were dated and timed, that all IV infusions were dated and timed, and if we all knew the policy of same. To take it one step further, then it was checked that each person with an IV had a skin integrity care plan, and that in fact it was looked at, reviewed and initialed. (as well as each patient having an alteration of bowel pattern care plan if they were on any pain meds, reviewed and initialed as indicated--story for another thread HAHA). Most EMR's do this from a "problem list" perspective now.

    From what I have observed, the bottom line is that insurances will not and do not pay for hospital acquired infections. And IV site issues can ("can") be the result of not changing the tubing. With that being said, the on off of a secondary is certainly a risk, however, it is a practice thing at my facility.
    GrnTea likes this.
  13. Visit  MunoRN profile page
    0
    Quote from jadelpn
    Yes. The secondary is disconnected from the primary fluids, and capped. Due to multiple secondary infusions over a period of time, or a practice issue to just have primary running--nurses will do it both ways (but I have also seen the primary "back up" into an empty secondary, this avoids the issue)And depending on pump, free flow...
    Secondaries shouldn't be disconnected from the primary once connected, they should remain connected, backprimed between antibiotics, and changed with the primary set. I would agree that if the practice is to disconnect between doses then changing tubing doesn't add any additional risk of contamination, it's higher than it should be either way.

    Quote from jadelpn
    Either the tubing is primed and reused if it is within the 24 hour time period. All have to be labelled. And our policy is still 72 hours for fluids, as it coordinates with the IV rotation. And of course, it there's no fluids just IV infusions, then the primary is taken off and capped for reuse or a new set if after 24 hours, IV becomes a SL.

    The current CDC recommendation for IV site rotation is 96 hours, sites and tubing should be done at the same time. Supposedly the INS is heading towards site rotation based solely on assessment.

    I think the bottom line is the push to reduce/eliminate hospital acquired infections. When we were surveyed, there was checking of all IV sites that they were dated and timed, that all IV infusions were dated and timed, and if we all knew the policy of same.
    From what I have observed, the bottom line is that insurances will not and do not pay for hospital acquired infections. And IV site issues can ("can") be the result of not changing the tubing. With that being said, the on off of a secondary is certainly a risk, however, it is a practice thing at my facility.
    More frequent tubing changes = more contamination and more resulting infections. The only exception to this is tubing infusing fluids that can support bacterial proliferation such as lipids, blood, etc.

    Of the studies the CDC based their recommendations on, two showed a significant increase in infections when tubing was changed every 24 hours compared to 72 hours or greater, none showed a significant increase when tubing was changed less often than 24 hours. In other words, with a few exceptions, changing tubing has no potential effect other than to increase the opportunity of contamination. So if you're having to re-prime and reconnect tubing anyway, it probably doesn't create any increased risk in changing the tubing. But if we're taking tubing that otherwise would have remained connected for 96 hours, and changing at 30 hours instead (because the tubing was momentarily disconnected after 6 hours to remove a splitter for instance) then all we're doing is potentially introducing more bacteria without any potential beneficial effect to weigh against that.
  14. Visit  jadelpn profile page
    0
    This is all interesting, and I will bring it up at the next infection control meeting. I think we need to get to a place where we are updating policies.....


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