CVC mess-up?

[arieseff]

Hi, new RN here, and I am hoping someone can help set my mind at ease/ advise me about something that I did on my shift today, that I can't get off my mind.

When disconnecting a central line IV infusion, I inadvertently disconnected the needless access device along with the tubing, and didn't realize. Then I flushed it and capped it, all correctly and safely, just without the actual device in place (directly into the port). I clamped it safely before completely emptying the flush, and it remained clamped and capped throughout the shift.

Later, the next nurse alerted me that I had disconnected the access device and showed me. My heart dropped into my stomach, but neither of the more experienced RNs I was working with seemed to think any ill effect could come from it, since it was clamped and clean. But one of the RNs did question whether air could get in without the access device in place. I'm just so restless thinking about it, and hoping to get some clarity about what I should have done differently or what I can do.

Thanks so much (at the time I left, having no access device for 7 hours, the patient had no signs of trouble)

[Okami_CCRN, BSN, RN]

I am a little confused, you mentioned that you removed the needless access device and flushed and clamped. Did the lumen remain open to air? meaning there was no cap on the opening? If so that is a problem.

[iluvivt, BSN, RN]

Let me get your terminology correct so you can explain what you did. A needleless connector (NC) is what is attached to the hub on the tails of a CVAD. It sounds like the NC came loose with the IV tubing still attached. At that point.you should immediately clamp the CVAD if there is a clamp. If there is no clamp it means it is a valved CVAD) includes(PICCs) and the valve will remain in a neutral position. You could also place your patient supine to prevent air embolism. Cleanse the hub with isopropyl alcohol (IPA) for 15 seconds.. Wrap it around the threads and scrub it well... Then take a prefilled MS and attach your NC to it and prime it...then attach it to your cleansed hub.. Make sure the IPA is dry or it can act as a bonding agent and make the NC difficult to remove... then verify a brisk blood return and flush.... next

scrub the NC with IPA for 15 seconds and attach the IV tubing. "I am a liitle confused about your corrective actions... Did you just hook up the IV tubing directly to the hub of the CVAD and not add the NC. If you did that.. that is ok too and it's a quick fix until you can add the NC. If the pt were to experience an AE it is sudden and you would know it by the symptoms. Do you know what to do if that happened? It is really critical to not skip the cleansing steps in this process.. Your risks here are for AE and introducing bacteria causing a site or bloodstream infection.

[iluvivt, BSN, RN]

Did you just clamp the CVAD and apply no NC to it?I hope not as that would be an infection risk not to mention the fact that the clamp could be unclaimed and you risk air embolism and exsanguination

[arieseff]

Thanks so much for your reply. The problem is I don't have enough experience with central lines and as dumb as it sounds, didn't realize there even was a needles connector. But yes, I cleaned, flushed, clamped and capped the port directly. The port stayed clamped and capped. A needles connector was applied once someone realized my mistake. I am going to take this opportunity to ask for some training since I obviously could use it

[arieseff]

No, like I said, the port stayed clamped and capped throughout the shift. I know its really dumb. I basically did every important infection control/safety step to a T, just without the needless connector where it should be

[GIEndoRN, BSN, RN]

Obviously for infection control purposes, this was not ideal, as "cap" (needleless connector) changes should always be a sterile procedure. As far as direct harm to the patient, since the line was clamped and capped, it's fine. Sounds like you cleaned the site well, so I wouldn't expect there to be any problems. Mistakes are a learning opportunity and I'm sure it will stick with you forever!

I would approach your unit educator. Sounds like your unit needs an in-service! There are likely other nurses who are not comfortable accessing CVCs as well.

[chare]

No, like I said, the port stayed clamped and capped throughout the shift. I know its really dumb. I basically did every important infection control/safety step to a T, just without the needless connector where it should be

I'm still not following this. When you "capped" the port, what did you use?

[arieseff]

Thank you so much. I am indeed taking it as a learning experience and will never, ever forget it!

[arieseff]

When I say "cap", I am referring to a sterile, alcohol-infused orange cap we use to cover PICC lines when not in use.

[Cvepo]

Our docs throw in lines and don't put caps on, forget to clamp, etc. It's awful. You recognized your mistake, and will learn from it (unlike them)! Clean, clamped, connected -- your 3 C's for CVCs!

[Julius Seizure]

Once upon a time, a long long time ago (well, not THAT long ago), there were no "needle-less connectors". Not much needle-less anything, really. Those little alcohol-infused caps didn't exist until recently, either. IV tubing and syringes were hooked up directly to the end of the central line, which was cleaned well with alcohol swabs and care was taken not to introduce air into the line by clamping the line whenever it was unhooked. Now, times have changed and needle-less connectors are great, but what it sounds like you did was basically what everybody used to do before those connectors existed. It is fine. The line was cleaned appropriately and clamped.

Just ask for the extra education like you said you wanted to do, and practice your technique.