Do you scrub the hub of a PICC between each medication?

Mollsythejollsy · Oct 19, 2019

Hi there

I worked in Renal dialysis 2 and 1/2 years and not that we would use PICC lines but we would use permanent indwelling catheters (femoral or sub-clavicular) so the process would be similar with flushing and locking the line with saline. We were always trying to do ANTT (aspetic non touch technique) for each time we would perform the procedure.

So first you get your trolley and all your supplies or tray if that's what you normally use.

Supplies I would use 1. Dressing pack with sterile gloves or something that you can create a sterile field with

2. Syringe for saline and for heparin

3. Saline and heparin

4. Green needles (needles big enough to draw up your heparin)

5. Your cleaning wipes for your hub end (I use the small green cholorixhinde wipes but not sure what your unit requires)

6. Your caps / end bungs (I use the completely enclosed ones not the ones that you would like put on the end of a venflon due to the chance of infection etc).

6. Hand gel

Then clean your tray / top of trolley from inside to outside with your proper wipes (I am not sure what your unit uses but we use a chlorine wipe) Don't put out your stuff yet. Either keep it aside or on the bottom of your trolley (we have trolley with these supplies inside for ease of use so you could have that!)

While it is drying go and wash your hands using good hand washing technique.

Once hands are dry open up your dressing pack.

When you have taken off the plastic outer cover you'll need to gel your hands with your hand gel.

Then open up your dressing pack careful not to touch the inner parts of the field you are creating.

If it comes with a plastic bag go ahead and take your plastic bag and put your hand inside to cover your hand. Then you take items in dressing pack (swabs tray and gloves) and place them how you like in your field. Put plastic rubbish bag on side of trolley or nearby your tray. If it doesn't come with bag then just go ahead and open up all your supplies onto your field.

Note: Heparin does not go onto your field so either place that on your trolley outside the field or in the tray which comes in our dressing packs separate from all the other sterile items.

Note: Saline I squirt into the separated area of the tray which comes in our dressing packs (this is still ANTT) or you can do the same as you've done for the heparin -keeping it to the side. Make sure both these items are open though before you start!

Gel hands and wait to dry (stingy!)

Open up sterile gloves and put on sterile gloves (loads of YouTube videos on how to do this).

Take your dressing drape (again this comes in our dressing packs) and slide underneath permcath taking care not to touch permcath. Patient can assist by lifting the tube of permcath for you or your assistant can help too!

Then take cleaning swabs and wrap one around the venous end and one around the arterial end. Clean for 30 seconds.

Once clean take pile of swabs (again in our dressing packs) and slide underneath the permcath.

Wait for drying - roughly 30 seconds again so while this is happening you can draw up your saline and heparin in a sterile manner (wrap swab around vial and draw with syringe) or in case of if you have opened and squirted saline into tray just drawing up with your syringe.

I'm just gonna imagine we are re locking the lines after let's say an infusion or dialysis so just imagine we already know that the heparin lock is out in this example!

Make sure A line is clamped.

Take cap off of A line while holding your syringe of saline in other hand - you want to kind of immediately get it onto the end of your bung ASAP unclamp and flush line. Then clamp the line.

Repeat for V line.

Leave syringes on end once you have done flushing.

Get your heparin syringes and basically do the same as above. Make sure you clamp and unclamp when required!

Then put your caps on the end of both lines ensuring they are on tightly and both A and V lines are clamped!

Not sure if picc lines are the same as permcath but hope it helps!

Hope this helps!

**canoehead, BSN, RN** · Oct 19, 2019

I don't scrub between meds if it's been in my sight, and less than ten seconds.

Kooky Korky, BSN, RN · Oct 20, 2019

sounded like she walked away to go get the Heparin.

The term she used probably means something different wherever she lives/works/goes to school. I hope it does. Otherwise, it sounds like she walked away and I wonder why she didn't have the Hep with her instead of having to go get it.

JKL33 · Oct 20, 2019

13 hours ago, Kooky Korky said:
sounded like she walked away to go get the Heparin.
The term she used probably means something different wherever she lives/works/goes to school. I hope it does. Otherwise, it sounds like she walked away and I wonder why she didn't have the Hep with her instead of having to go get it.

Yes, it's true, if things don't make sense then maybe we aren't reading them as intended. I don't know anyone who was taught that leaving the room/releasing control of the line without scrubbing again was the proper way to do things, do you? Whatever the OP's action was, s/he says it was how both s/he and preceptor (separately) were taught. I kind of think s/he is referring to the idea that they were taught that as long as control of the line/hub is maintained then scrubbing again is not necessary. [I'm not arguing whether that is right or wrong, just that other interpretations of what was said are less likely].

What shall I make of all these ED patients who say they "went to grab" (reached for) a railing and missed (or their knee gave out)? They left the steps to go get the railing? ??

JKL33 · Oct 20, 2019

I picked up my phone and just as I went to answer it the battery died.

At the gas pump I went to put the nozzle into my gas tank and gas dripped all over my shoes.

I went to take a bite of food and my jaw popped.

I went to start my dishwasher and nothing happened.

These actions do not involve worldwide travels, nor leaving the position one was in when they "went to" do something.

The OP uses the same exact verbiage twice:

On 10/16/2019 at 11:36 AM, Kara Hoffman said:
Hi! I’m a new grad currently orienting to my unit and this question came up the other day. Basically, I was heparin locking a PICC at shift change. I disconnected the IV tubing, scrubbed the hub, attached a saline syringe and checked blood return then flushed. Then, I went to grab the heparin flush. I asked my preceptor if I needed to scrub the hub again before attaching the heparin flush, and she said no (which is also how I learned to do it during my critical care rotation in school). So I uncapped the heparin and went to attach the syringe, and the oncoming nurse I had given report to kind of hit me on the shoulder and said “alcohol swab please.” I’m not confused on which is the proper practice, and we didn’t have time to see if our hospital policy addresses this.
So, if you’re giving multiple meds or flushes through a PICC at the same time, do you scrub the hub before attaching each syringe, or do you just do it once?

? This is not a crime scene where we need to postulate about "what really happened here."

I will translate:

"As I was reaching for the heparin flush..."

"As I was moving my syringe-holding hand toward the hub to attach the syringe..."

MunoRN, RN · Oct 21, 2019

On 10/19/2019 at 3:16 AM, CapeCodMermaid said:
Who said the INS is of questionable reliability? Many policies at many facilities are based on their recommendations

There are number of criteria to be a reliable evidence based source that they fail to meet.

I've worked at a couple of different organizations where the medical librarians refuse to have the INS recommendations on their shelves, they at least claim that their reasons are shared by medical librarians in general:

Their recommendations are often not based on evidence or anything accurately described as expert consensus.
Their recommendations are not publicly available.
They do not respond to feedback, criticism, clarifications requests, etc regarding their recommendations. Their recommendations primarily come from a single person, and if you seek further information regarding recommendations from that person, they will only respond to those requests for a fee.
Their recommendations are often non-sensical and based on a poor understanding of the available evidence and terminology, their recommendation on administration set changes for instance.

And while you're correct that many facilities adopt their policies, what's more alarming is the number of facilities that don't, which is pretty much every facility that applies any sort of critical analysis to their recommendations.

Career Columnist / Author · Oct 21, 2019

12 hours ago, MunoRN said:
There are number of criteria to be a reliable evidence based source that they fail to meet.
I've worked at a couple of different organizations where the medical librarians refuse to have the INS recommendations on their shelves, they at least claim that their reasons are shared by medical librarians in general:
Their recommendations are often not based on evidence or anything accurately described as expert consensus.
Their recommendations are not publicly available.
They do not respond to feedback, criticism, clarifications requests, etc regarding their recommendations. Their recommendations primarily come from a single person, and if you seek further information regarding recommendations from that person, they will only respond to those requests for a fee.
Their recommendations are often non-sensical and based on a poor understanding of the available evidence and terminology, their recommendation on administration set changes for instance.
And while you're correct that many facilities adopt their policies, what's more alarming is the number of facilities that don't, which is pretty much every facility that applies any sort of critical analysis to their recommendations.

Actually the Infusion Nurses Society (INS) Infusion Therapy Standards of Practice 2016 is considered the gold standard by Lippincott (Wolters Kluwer) and is the basis for their evidence-based procedures.

As a Nursing Professional Development Specialist, the INS is my go-to source for infusion therapy.

Kara Hoffman · Oct 22, 2019

On 10/16/2019 at 9:56 PM, LovingLife123 said:
Yes, you should have scrubbed. I don’t understand the rationale for not scrubbing. You put the hub down, left the room. The hub would have come into contact with possible bacteria in that time frame.

I didn’t know facilitates still heparin locked piccs.

I did not leave the room. The heparin flush was on the bed right in front of me, still capped. I held the hub, did not let it touch anything after disconnecting the saline, and uncapped the heparin flush.

Kara Hoffman · Oct 22, 2019

On 10/20/2019 at 10:17 AM, JKL33 said:
I picked up my phone and just as I went to answer it the battery died.
At the gas pump I went to put the nozzle into my gas tank and gas dripped all over my shoes.
I went to take a bite of food and my jaw popped.
I went to start my dishwasher and nothing happened.
These actions do not involve worldwide travels, nor leaving the position one was in when they "went to" do something.
The OP uses the same exact verbiage twice:
? This is not a crime scene where we need to postulate about "what really happened here."
I will translate:
"As I was reaching for the heparin flush..."
"As I was moving my syringe-holding hand toward the hub to attach the syringe..."

THANK YOU. Not sure why people would think that TWO experienced nurses (since i stated both were in the room) would even let me leave the room with an uncapped PICC hub hanging out to grab the flush that i obviously should have had in the first place.