Habit

iluvivt, BSN, RN · Dec 30, 2010

Yes the term that the infusion nursing community has come up with is "looping" and as you may be aware it is an unacceptable practice and violates the INS standards of care. Those standards call for a sterile end cap to be used on any disconnected IV tubing that will be used again. These caps are made by many manufacturers..the most common colors are white,red and blue. We requested red ones for our staff.It is not acceptable to use the end of a NS or heparin pre-fill. I have seen those used as well. Needleless connectors have made it easy for nurses to take a short cut that compromises IV tubing. I remember reading one of those FDA alerts about this unacceptable practice. We had to a lot of training to get a high rate of compliance and also made certain we had the end caps available in all clinical areas.

picclineman · Dec 30, 2010

I realize it is an unacceptable practice, however i have not found a good rationale why it is unacceptable. When nurses clean that injection site using the 15 seconds scrub, leaves it to dry before flushing it and it is found acceptable, why not looping,if the same injection site is thoroughly cleaned before the male luer of the same tubing is attached. It has the same reasoning, right? You know of any research done on this area? I also realize that we IV nurses being in this field for a long time have a lot of bright ideas, however they remain ideas until it is proven correct by a research and is written as a policy. I am a hospital contractor doing PICCs for 8 hospitals and nursing homes. I do teaching too. I have so many ideas but no research so my ideas remain as is. As you know registered nurses are intelligent people and i find it hard to just tell them to follow. There is a common rationale they tell me.. " it is my license" and me being an outsider and have business interest have to be really careful i dont offend anybody.

Thanks for you input..

iluvivt, BSN, RN · Jan 1, 2011

Ok I understand where you are comimg from..they have there policies and procedures. Yes sometimes it takes time to update practice, however, I believe you should always let them know what the current standards are. In this case

The INS standards of practice supports the practice of applying a new sterile dead end cap or new blunt cannula (if you use that system), and not looping the tubing to another injection site. A new sterile end cap is specifically written in the standard on intermittent tubing. Also the Institute for Safe Medications Practices has written warnings about this looping practice - www.ismp.org.

Yes we all like EBP but the reality is not every issue is or can be completely researched so you use the current evidence to have to set a standard for the safest and best nursing practice. If an institutions practice is not up to date and does not meet the standard a nurse can still be held accountable even if they followed their policy. I understand the point you are making but you need to consider a few things. The purpose of the port on the IV tubing is to add another IV or give intermittent or push medications. It was not designed as a docking station for the distal end of IV tubing. You may be aware that the recommendation for primary intermittent tubing is to change that type of tubing every 24 hours b/c of the constant connection and disconnection will increase the risk of contamination and therefore biofilm and infection . It is the same with any medication port that is constantly being connected and disconnected..the risk for infection goes up. Some places have the habit of having multiple secondary lines instead of using backpriming...so that tubing too should only be used 24 hrs per best practice. As an RN I would feel much safer using the primary intermittent tubing that had a sterile end cap on it than unlooping the end and using it......I can at least have a reasonable assumption that it is not contaminated wheras if looped I would have to assume a 15 second scrub was done each and every time. Every time the tubing is looped the risk for infection goes up b/c the system has been entered again. We are not even sure about the 15 seconds..there is still not a lot of research. There are 2 studies out there....where it showed that 5 seconds was not enough but 15 seconds was better in getting the bacteria off. The other issue that the injection ports that are more distal tend to be in the bed....touching bed rails.......they can get all kinds of bacteria on them. It just makes sense that you keep the distal end of the tubing covered with a new sterile end cap upon disconnection. I would print out a copy of the ISMP report and share with them...why would any intelligent nurse NOT want to give the best and safest nursing care when they can. The caps are so so cheap...its such a simple thing to pay attention to detail but can have a significant impact in decreasing infections. I thimk in many places it is commonplace to forget that the fluid pathway and distal end of IV tubing needs to remain sterile. The ISMP statement is in their July 2007 issue

picclineman · Jan 1, 2011

I think i also know what you have just lectured me on. I have a CRNI certification and familiar with the INS Guidelines. I appreciate your lecture. What i was looking for was a rationale why looping would not be acceptable if the nurse does the 15 second or whatever second scrub rule, is used. If you really think about the whole practice of infection prevention, we are trying to implement a system that would achieve the goal of eliminating infection amongst central line. What you are telling me is YOUR preference. My nurses are asking me these questions and i kind of understand them. I always assume that there are more intelligent people than me out there even if they were not IV nurses. Again i will ask you, do you know of any research that proved that using the sterile end cap has a lesser infection rate than cleaning the hub of the IV tubing using the 15 second scrub rule then immediately attaching the male luer of the same IV tubing. If i can show this to them, i would have a more convincing rationalzation. Just because i am a certified infusion nurse, member of so and so organization, to me does not mean i know everything, i might know a lot but not all would be convincing. Just like what you are telling me now. I do not mean to argue with you on these points. The help I am asking out there is IF THERE WAS OR IS A RESEARCH ABOUT USING THE END CAP VS LOOPING AS AN EFFECTIVE WAY OF LESSENING INFECTION AMONGS CENTRAL LINE. I have read an article oN the site of LYNN HADAWAY ( I am convinced she is an authority on Infusion Nursing) and she mentions that "looping" is unacceptable HOWEVER, she also does not give a rationalization as to why looping is not acceptable. BRAUN company also suggests use of sterile end cap and i undestand why they would want it. Its more sales for them.

Again, to all the nurses who would like to help me out on this topic, i appreciate all your help. What I am looking for is a research.

iluvivt, BSN, RN · Jan 4, 2011

Well I am sorry you felt like it was a lecture...IT IS NOT.perhaps you are too sensitive.and just took it that way...My nursing style has always been to share what I know with passion. You will not find a specific study that proves "looping" is a safe practice even if the injection port is scrubbed...heck there are only 2 studies that even look at the correct amont of time to scrub a cap or injection port in order to remove the bacteria . The one most commonly sited is by Kaler...that is one the that the 15 seconds come from. There have been many many studies over the years that show the more times you enter an IV system the greater risk of infection and that is where the standard basically comes from. You want to limit the number of entrances into the system and if you use the injection port for things other than an injection it is an unneccasary entrance into the system. When I get to my office I can list a bunch of those for you if you so desire..In the meantime we all should follow best practice.....if another nuse insists on research and EBP that is not there and they can not understand where standards come from.. I am not certain what you can do for them. Try Lynn Hadaway blog or ask on ivtnet for more suggestions .....I also am an active member of that site as well ...... see what responses you get there..they are a lively group. Would you want someone to loop your IV tubing...I would not....not with the inconsistent way and total lack of regard I see for I systems in my hospital. Also did you check theISMP as I suggested to read the warning. Why are you getting so much resistance from the nurses?

picclineman · Jan 4, 2011

Thanks for the passionate response. I definitely appreciate it. I see where you are coming from. I am just trying to understand where a non IV nurse come from, how they rationalize there actions and so i will know how to help them. I respect their reasoning. There are a lot of policies that just doesnt make sense just like a lot of other nursing policies are purely out of this world. I would like to discuss this issue further, because i can see where the nurses come from. If we can make sure that the 15 second scrub is followed we can make sure then that the hub is clean and so looping would be okay. how about we do a research!! I can see why not!! When a nurse disconnects the IV tubing from the PICC, cleans the hub of that IV tubing vigorously, 15 20 secs, leaves it to dry and loopes it, that would clean that site. Wouldnt this be same as disconnecting the IV tubing, cover the end with a sterile luer lock and the next time the nurse accesses the hub of the PICC, clean it with 15 sec scrub and reconnect. The issue then is the nurse cleaning the hub vigorously , leaving it to dry before reconnecting it.. I have observed amongst nurses myself, and my observation is huge and varries with type of nurse because i see nurses at general hospitals, nurses at acute long term hospitals like ventilator hospitals, nursing home nurses. There are a few nurses that scrubs the hub of the IV tubing or the hub of the venous access before they connect a syringe or an IV tubing. I think the issue is cleaning as opposed to where it is connected. Otherwise if the issue is disconnecting and reaccessing again, and not sure if the nurse scrubs the hub,then the solution is use IV tubing one time and discard. This way , the nurse does not have to worry about contamination. This is a huge issue!!! wouldnt you agree?

I do not easily give up.. I will continue to research on this issue. i read lynn's site and she says the same reason why looping is not favorable. She is afraid nurses dont clean the hub vigorously. IVnet had something about the topic but has the same reasoning.

I hope you dont shy from sharing your ideas in the future. Thanks a million...

iluvivt, BSN, RN · Jan 4, 2011

No...I will never shy away from sharing my opinions and I base them on experience and 29 yrs of actively reading research articles and keeping up with the INS standards....NAVAN.....CDC.....ISMP.....IHI....plus many more. I refuse to take any shortcuts that can potentially harm someone. Yes beleive me I understand how nurses can be and I have had a few battles to get and mantain the highest quality of IV protocols in the facilty that employees me. I also do home infusion nursing as well. Lynn Hadawy has a wonderful explanation somewhere that explains how standards come about and what INS does when there is not enough research on a particular topic. ...I will see if I can find it and post it here for you....OK

iluvivt, BSN, RN · Jan 4, 2011

Here is some more info for you .....

Dr. Bill Jarvis emphasizes 15 seconds based on 2 studies. One my Menyhay and Maki which showed that 3-5 seconds is not sufficient and the Kaler/Chin study which showed that 15 seconds with either IPA or CHG/IPA was sufficient. That is all we have at the moment. Naomi O'Grady, principal author of the CDC guidelines suggested that all antiseptics would be included for cleaning needleless connectors. The CDC document also got changed in 2009 to read "scrub" as opposed to just wipe or swipe.