line flushes, patient safety, infection control

[LillyFish]

I have witnessed several nurses performing saline flushes on lines when administering meds, drawing blood, etc. I'm hoping someone can tell me if this is correct procedure because I don't want to be doing something wrong: First, the nurse prepares the prepackaged flush by removing the air in the syringe. He/She takes the cap off the end, careful not to touch it to any surfaces, pushes the plunger until the saline is at the tip and air is expelled, then replaces the cap. (seems safe to me, no contamination). Next, cleans the access cap to the patient's line with alcohol, uncaps the flush and pushes anywhere from 3-5 mls saline into the line, then removes the flush, lays it on the bedside table tray or the bed (this is where I'm concerned), pushes the next syringe of medicine (ok here-no comtamination), and then picks the flush back up and flushes the line again with 3-5mls. My problem is with the second flush. Is it, at this point, contaminated? And should a nurse technically be bringing two flushes to the scene? I have also seen a nurse draw up meds into a syringe, take off the needle, and haul it uncapped to the bedside to administer. I have personally left the needle on and capped, and removed it at the bedside, making sure to throw it away when I'm done. I feel like the fewer times I recap something, the better. Thoughts?

[eatmysoxRN, ASN, RN]

I don't recap my flush. I also scrub the hub before doing anything. I draw things up at bedside. If I sit anything down uncapped I put it on an alcohol pad.

[amoLucia]

I clean off the access port first, then uncap my saline, shooting off the air. I then straight-away connect to my port to inject my solution. I try my most to minimize having any uncapped syringe to use. When I uncap, I'm ready to use it.

[LillyFish]

I think putting it down on an alcohol pad is a good idea. I've done that when I've only brought one flush. Glad to know someone else does it too.

[IVRUS, BSN, RN]

Prefilled syringes are designed for single use only. Therefore, once the line is flushed and the syringe is put down, a SEPERATE syringe should be used with its saline in it to do the final flush after the push med has been administered. However, please know that the Standard of Practice is to scrub the Injection cap for a good 30 seconds or so and then flush, scrub with another alcohol pad x 15 seceonds and then push the med, disconnect, scrub again, and then final flush. Most bacteria enter IV catheters after dwelling a week or so through inappropriate hub cleaning and maintenance.

[Aurora77]

IVRUS, can you show some documentation for the multiple scrubs? I was taught to scrub once at the beginning. I did some googling and found several P&Ps that go along with this.

[IVRUS, BSN, RN]

There are studies which show that CRBSI's are r/t inappropriate hub cleaning and maintenance. Therefore, ask any IV expert and they echo the fact that the more you scrub, the decrease in infection rates occur. It is "standard" in many institutions in which CRNI's are writing the policies. If you do not have Infusion Experts in house, what harm is there to follow the most up-to-date standards besides an extra minute of your time for 4 swabs?

[Aurora77]

I understand that. I was hoping for a study or two to show that scrubbing multiple times is the most up to date standard.

[LillyFish]

I definitely see the need to scrub the hub, no doubt. But in between med pushes/flushes? I'm a recent grad and I was taught that evidence based practice is to scrub for at least 15 seconds (when I started school it was 30 sec) at the beginning, and again only if the hub is put down or touches something. I work at a hospital where central line infections are very, very low, and my nursing textbooks as well as instructors have taught one scrub at the beginning. I too am interested to see the evidence on multiple scrubs. I appreciate your input! :)

[donnask]

Yes the first flush is contaminated as you have entered a closed system. Do a literature search on reusing flushes and you will find there is the potential of bacterial contamination and when you flush again you are flushing potentially bacteria into the patient. The CDC just released new guidelines for the practice of IV therapy and infection prevention.

The issue of placing the flush on the alcohol prep pad I ask you do you know how long C diff spores live on a surface? 5 months.......ok next question, what will not kill C diff spores? Alcohol, so what if this was your mother, the nurse accidentally contaminated the syringe with C diff spores.....this is how transmission occurs.

Have you seen the Curos caps, this will solve your problem.

Donna Stanley-Kelley, RN, BSN, CIC

[ckm2]

According to CDC and manufacturers prefilled syringes are Single Use which means One Time Use, not single patient. If its a TLC triple lumen cath it needs 3 separate prefilled flushes. Once a prefilled syring is used it is NEVER recapped and reused; it hits the needle box. Leave it on an alcohol wipe on a dirty table... gross.

Visualize this, you have a TLC. each port has its own probability to be contaminated by any number of microbes ( inadvertant touch contamination usually transfers Candida Albicans and Staph Aureus. Lets say they have mainly been using only one line for IVs solutions and the outside of the hub has normal hand flora of the above.( Good reason to use gloves when you touch patients; this is is normal hand flora and it is not alleviated by hand washing only reduced)

If you were using the same syringe to flush: First you flush

3 mls into the used hub( ok maybe you have really clean hands but can you trust the other 10 people who held this hub in their hands )

The flush now has the above flora on the inner hub, now use this same syringe to flush the other 2 lumens

with the remainder of the flush and you have transferred the perfect storm of a line infection, CLABSI which kills about 100,000

folks a year.

For those who are trying to be frugal, the cost of a prefilled to the hospital is 0.18-0.30 cents depending on what purchasing contract they have. The charge to the patient is for internal accounting purposes, CMS and insurance companies pay a flat fee

based on the diagnosis( DRG) Its price fixed, one rate for a diagnosis and they dont care how many flushes you use or dont use.

Well actually they do, if you cause a CLABSI in their patient CMS aint paying for you to fix bad practice. HAI hospital acquired infections are now mandated to be published "transparency in healthcare" The major insurers will follow suit in the next few years.

So if you want to really want to "help your hospital to be accountable please splurge on prefilled syringes; you may be saving a life!

And yes Scrub the HUB! You may think your practice is pristeen ( you are not) but there are others who have left their microbes before you!

Think about it!