Fluid Changing practices

[NANSNURSE]

Hi All,

I was wondering what everyone did when they changed their TPN/IL. How often do you change the tubings, how do you change the tubings, etc.

We:

1. Change TPN q24 and IL q12.

2. Lines are hung "cleanly" as opposed to sterilly. Honestly I think they are changed dirty because we don't use any sort of sterile field, just the packaging the tubings come in, and we change them and then walk across the room to hang them, rather than just hang them at the bedside.

3. We use a system that has a trifuse that directly connects to the PICC/UVC/PIV, etc. and then the IL tubing and TPN tubing connect to the trifuse. We change the tubings q24, but the trifuse q72. We are thinking we should change everything q24.

Thanks in advance for any feedback you can offer.

[ilstu99]

What do you mean by providers?

Either an NNP or an MD.

[texas2007, BSN, RN]

Either an NNP or an MD.

Wow that would never see the light of day at my hospital. Are you a smaller unit?

[elizabells, BSN, RN]

Wow that would never see the light of day at my hospital. Are you a smaller unit?

That does seem a little restrictive to me. We're not technically allowed to draw off of or flush a PICC, but occasionally if we need a culture we'll go ahead and do it when we change the lines if the provider isn't available, so as to avoid opening the line at the hub more than once that day. The hubs are, I think, supposed to be changed qweek with dressing changes, but I never actually watch the dressing team do it, so I don't know if it happens. We change the tri-fuse q96, TPN running more than 10ml/hr q96, TPN less than 10ml and lipids q24, and med tubing/clear fluid tubing q96. Sterile technique, not at the bedside.

[texas2007, BSN, RN]

We are now doing full line changes, including the triple connector, q-day, so no more 'pulling through' TPN. This is supposedly per CDC recommendations but sounds like one more thing to waste supplies (and my time) on. We had already gotten our line infection rate pretty low (like one a month) so that's probably unrelated to the triple connector anyway... Actually it seems like more opportunities for line infections by breaking into the line 3 times more often but I'm JTN, what do I know...

[MA Nurse]

That does seem a little restrictive to me. We're not technically allowed to draw off of or flush a PICC, but occasionally if we need a culture we'll go ahead and do it when we change the lines if the provider isn't available, so as to avoid opening the line at the hub more than once that day. The hubs are, I think, supposed to be changed qweek with dressing changes, but I never actually watch the dressing team do it, so I don't know if it happens. We change the tri-fuse q96, TPN running more than 10ml/hr q96, TPN less than 10ml and lipids q24, and med tubing/clear fluid tubing q96. Sterile technique, not at the bedside.

Q96 hrs. is a long time, IMO. Does your unit have an issue with line infections?

[elizabells, BSN, RN]

Q96 hrs. is a long time, IMO. Does your unit have an issue with line infections?

Quite the opposite, actually, although we used to when we changed everything down to the hub q24. This policy was developed out of an ID study to reduce CLABSIs, and it's worked quite well. We've gotten good enough that any CLABSI results in an inquiry by ID to find a possible cause.

[ilstu99]

Wow that would never see the light of day at my hospital. Are you a smaller unit?

Medium. There are multiple providers on the floor during the day, and usually a couple on nights and weekends. They do all dressing and equipment changes PRN. It seems to work for us. If I need a culture or there's an issue, I just ask if they have a few minutes, and we get it done. In a real pinch, someone on the flight team can do it, but that would be rare. Our line infections are almost non-existent. When they do happen, the team "gets to" participate in a non-punitive review of care to see if they can figure out where the breakdown might have happened.

The only providers I never ask are the residents. They're the bane of my existence at the moment.

[skunkdog]

We change central lines with TPN & IL q 24 hrs and change them use sterile tech.

[SteveNNP, MSN, NP]

Like Elizabells said, our CLABSI rate is pretty good. We just went 196 days without a CLABSI in our

[Preemienurse23]

Any PICC line tubing and the fluid bag are changed q24. We run our lipids in our TPN so we change that q24 on both PICC and PIV. As far as clears, if it is just plain D5,10 etc and a PIV, we change tubing q72 and the bag q 24. If there are additives in the clears we change everything q24.

I assemble my tubing/medlines at the bedside on a steril towel, as clean as I can , but I dont use sterile gloves to assemble it. Whenever the PICC line is disconnected, we must wear sterile gloves. None of it is truly sterile, just super clean.

[santababy52]

I have some questions regarding changing TPN on neonates. #1-what is the point of wearing sterile gloves, gown, mask, and cap to spike a unclean TPN bag that has been handle by pharmacy in questionable clean handling and spiking that bad with non sterile tubing, lipids microbore tubing, and a buretrol? Don't get it. Why not do it clean, keeping the end of bag completely sterile while you protect the spiking procedure and not contaminate spike to bag opening? #2 Ok I get creating a sterile field for dropping stopcock, fill needle for flush, syringes, open beta dine, alcohol, or other cleaning agents per specific to hospital, as well as a sterile field at hook up site at baby's bed--how do you get the isolette door open with sterile gloves on, occlude the umbilical catheter with padded hemostats and keep the field sterile? How many gloves do you go through and how hot do you get with all the extra ppe on board covered from head to toe. We have to have all that on even when priming the tubing. I believe it is overkill and would like to see some real EBP from real research to show that all of that is necessary because it is hot and time consuming.....and oh, let's not forget the amount of time it all takes. Get an admission when all that is going on and you are in the unit charting at 2130 like I was tonight. I am fairly new at this and so I am slow to get the hang of it. I welcome any helpful suggestions at stream lining my process!

[NicuGal, MSN, RN]

When you weight the time consuming tasks of making sure things are done correctly or according to your protocol vs the added length of time to a hospital stay and the possiblility of your hospital not getting paid for a central line sepsis and a baby possibly dying from sepsis, it is actually well worth it. You sound frustrated because you are new...do a search on preventing line sepsis...plenty of info, esp from the CDC and IHI.org As time goes on you will get the hang of it and get your routine down. Just like all other things....practice makes perfect :) Also, ask you nurse educator or CNS for articles to read...there is a mulititude of info out there.

We use two people so that the sterile person is only touching the cleaned port, of if we are pressed for people we will wrap the bag in a sterile towel so we can grab it.

You get your field together, drop what you need on it, open your isolette doors prior to donning your sterile garb (or at least your gloves) , occulude the cath before that too since you can do that ahead of time. Once you get your sterile gloves on, place your field under your line, put your tubings together, clean the ports to the bag and your connections and then spike the bag, take other connections apart and reconnect.

I can get a line done in under 10 minutes, but I have years of practice under my belt. You'll get it. Just remember....it isn't overkill, you are hopefully preventing a baby from getting sick or dying. And if that were your baby, wouldn't you want that?