Scrub the Hub

[ManNurseBear]

So last night I was doing my standard shift routine and I was getting ready for blood draws. They all went well except on one blood draw I forgot to scrub the hub of the CVC before I accessed it. I didn't realize that I did it until I was more than half way done with all of my vials I needed. I felt so stupid because that is such a simple thing to forget and I feel really guilty... But, my question is, how probable is it that the patient will get sick?

[Anna Flaxis, BSN, RN]

I cannot think of any situation where taking 3 seconds to scrub the hub is going to result in a bad outcome. On the other hand, I can easily imagine that repeatedly accessing a VAD without even a cursory effort at hub decontamination could result in a bad outcome.

[nrsang97, BSN, RN]

I know there are probably times where I have forgotten to scrub the hub in an emergent situation. Being a rapid response nurse we are often in emergent situations, and I always try to make sure I at least wipe the port.

I load my pockets at the beginning of my shift with alcohol swabs. I have gone into rooms to start an IV on one of the floors and see uncapped tubing and I toss it. Plus if I just started a new line for your patient please use new tubing.

I haven't ever done that.

That you recall, anyway...

It takes seconds

Well, to do it the *right* way actually pushes 60 seconds... scrub for 30, dry for 30...

Do you also skip washing your hands?

Hand hygiene... only if I need it or if I have the time to spare.

~~~

OP, now's a good time to read about SwabCaps and push for their implementation... they are clinically proven to significantly reduce CLABSI... and have become standard-of-care in these parts.

And chill... probably no harm done...

Bet you never do that again :-)

I was taking to the OP. I was talking to Dranger...

Well, in emergent... and I mean EMERGENT situations... corners do get cut... everybody does the best they can but sometimes, we're hoping to keep the patient alive *long enough* to be concerned about CLABSI.

For example, ever see an emergency thoracotomy? Not always the most sterile process just because sometimes the surgeons are just trying to keep them alive.

Same deal with central line insertions in the ED... on occasion, they're less than perfect because of everything else going on... they do their best but it's not always the controlled environment of an elective CL.

The point being, no argument with best-practice... but from my observation, the reality at the bedside occasionally results in compromise.

That said, I'm a stickler for SwabCaps.

[TU RN, DNP, CRNA]

If I was pulseless in need of ACLS drugs, I'd forgive the RN who forgot to scrub the hub to give them... might not be so quaint if they spent 30-60 seconds scrubbing the hub while my hypoxic brain tissue dies off.

[ChipNurse]

This is a poster that is in the med rooms at our facilities. As you can see, a simple wipe would do absolutely nothing in terms of removing the microbes from the hub. I am surprised that many people feel that a "quick wipe" is much better than nothing at all. Unless it scrubbed for 15 sec and left to dry 15 sec, then it really isn't doing much good for the patient in terms of protecting them from infection. However, I work in the ICU and am guilty of pushing drugs without wiping first if in an emergent situation.

[Anna Flaxis, BSN, RN]

If I was pulseless in need of ACLS drugs, I'd forgive the RN who forgot to scrub the hub to give them... might not be so quaint if they spent 30-60 seconds scrubbing the hub while my hypoxic brain tissue dies off.

This is a complete and total red herring argument.

If you were pulseless, you'd be in need of high quality CPR and early defibrillation. ACLS drugs are of secondary importance.

If your hypoxic brain tissue were dying off, it wouldn't be because the nurse took 15 seconds to scrub the hub, it would be because you weren't getting effective CPR.

Since it's predictable what drugs you will be getting and when, there is plenty of time to scrub the hub.

To me, saying there's no time in a code situation to scrub the hub is like saying there's not time to assemble the Abboject. Of course there is. You don't wait until the last second to pop the lock on the med drawer and pull out the epi. You know you're going to give it, so you get it all ready ahead of time.

[MunoRN, RN]

This is a poster that is in the med rooms at our facilities. As you can see, a simple wipe would do absolutely nothing in terms of removing the microbes from the hub. I am surprised that many people feel that a "quick wipe" is much better than nothing at all. Unless it scrubbed for 15 sec and left to dry 15 sec, then it really isn't doing much good for the patient in terms of protecting them from infection. However, I work in the ICU and am guilty of pushing drugs without wiping first if in an emergent situation.

Is there a reference for that? It doesn't appear to accurately represent the current evidence.

[Anna Flaxis, BSN, RN]

Well to do it the *right* way actually pushes 60 seconds... scrub for 30, dry for 30...Hand hygiene... only if I need it or if I have the time to spare.[/quote']

According to the INS, "The needleless connector should be consistently and thoroughly disinfected prior to each access on any vascular access device. The optimal technique or disinfection time frame has not been identified."

The 15 second scrub was based on one study. The 30 second recommendation is based on the assumption that if you recommend 30 seconds, then nurses will more reliably scrub for at least 15 seconds. One study even showed no difference between a 3, 10, and 15 second scrub.

And yet it has been well established that NOT scrubbing is a cause of CLABSI.

So in essence, we know that scrubbing the hub does result in reduction of bacteria introduced into the bloodstream. We don't know the ultimate time frame. We know that neglecting to scrub results in blood stream infections.

As I previously stated, I know of no situation where you cannot take at least 3-5 seconds to scrub the hub. Even in a code, since again, it is predictable what drugs will be given and when.

[MunoRN, RN]

According to the INS, "The needleless connector should be consistently and thoroughly disinfected prior to each access on any vascular access device. The optimal technique or disinfection time frame has not been identified."

The 15 second scrub was based on one study. The 30 second recommendation is based on the assumption that if you recommend 30 seconds, then nurses will more reliably scrub for at least 15 seconds. One study even showed no difference between a 3, 10, and 15 second scrub.

And yet it has been well established that NOT scrubbing is a cause of CLABSI.

So in essence, we know that scrubbing the hub does result in reduction of bacteria introduced into the bloodstream. We don't know the ultimate time frame. We know that neglecting to scrub results in blood stream infections.

As I previously stated, I know of no situation where you cannot take at least 3-5 seconds to scrub the hub. Even in a code, since again, it is predictable what drugs will be given and when.

We've found that pushing the scrub time recommendation longer than is actually necessary (there's not even good evidence that 15 seconds is necessary) actually backfires, nurses are actually less compliant with hub scrubbing, which you sort of get a sense of in this thread.

[Anna Flaxis, BSN, RN]

We've found that pushing the scrub time recommendation longer than is actually necessary (there's not even good evidence that 15 seconds is necessary) actually backfires, nurses are actually less compliant with hub scrubbing, which you sort of get a sense of in this thread.

I can believe this.

I don't claim to know how long, what technique, and what disinfecting agent is the most effective, but as I said, it has been well established that failure to adequately disinfect the hub does cause blood stream infections- so in my mind, even a 3-5 second scrub is better than none, and again, I cannot think of any emergent situation where one cannot take 3-5 seconds to scrub the hub.

[MunoRN, RN]

I can believe this.

I don't claim to know how long, what technique, and what disinfecting agent is the most effective, but as I said, it has been well established that failure to adequately disinfect the hub does cause blood stream infections- so in my mind, even a 3-5 second scrub is better than none, and again, I cannot think of any emergent situation where one cannot take 3-5 seconds to scrub the hub.

I agree that a 3-5 second scrub is better than none, and based on the evidence may not be much different clinically than a longer scrub duration, and as a nurse who's worked 'level I trauma' ER and ICU I should clarify that the views of other posters don't reflect the general views of such nurses in my experience. A quick scrub is the general expectation, no matter how emergent the situation.