A leader in our facility has reached out to me with a question from a dialysis nurse (from another facility somewhere in the country).
They are looking for specific guidelines to refer to in re: to scrubbing the hub (not the needleless connector - one of my pet peeves being that "hub", "cap", "valve", and "clave" are used interchangeably when meaning needleless connector, and it causes confusion). The hub meaning the proximal and female end of a central line that an end cap or needleless connector or administration set would attach to.
The concern from this dialysis clinician is that isopropyl alcohol will get into the inside of the catheter hub when disinfected, and will remain as residual, and therefore have concluded that they should not be scrubbing the hub.
My immediate responses are:
1. We're not scrubbing the inside of the hub.
2. We should be allowing the IPA to dry - when it dries, no IPA residual.
3. There is evidence that links CRBSI with contaminants on the catheter hubs - not just needleless connectors.
4. It is just common sense - if we know the needleless connectors have biofilm on them/in them, we know then that the hub will - because of the direct contact of the hub with the needleless connector.
I have several resources for them.
1. Hemodialysis Central Venous Catheter Scrub-the-Hub Protocol
(National Center for Emerging and Zoonotic Infectious Diseases; CDC Division of Healthcare Quality Promotion)
2. Salzman, Mark et. al. "Use of Disinfectants to Reduce Microbial Contamination of Hubs of Vascular Catheters",
J Clin Micro Mar. 1993 Problem with this article - they use "hub" interchangeably with "needleless connector".
3. Simmons, Sarah et. al. "Scrub the Hub: Cleaning Duration and Reduction in Bacterial Load on Central Venous Catheters"
Crit Care Nurs Q, 2011
4. 2011 HICPAC Guidelines
5. KDOQI guidelines
6. Marcia Ryder's work
I have plenty of evidence to share with them - they're already aware of Kaler/Chinn and needleless connector in vitro study, but I don't want to be dismissive of their concern. I believe strongly that they should be scrubbing the dialysis catheter hub, allowing it to air dry, and ensuring that it does not become contaminated once they've disinfected it.
Am I missing something here? I've never heard of the concern that residual IPA will cause a problem (and I'm not talking about degradation of the catheter - I'm well aware of that). If they are allowing it to air dry, isn't "residual isopropyl alcohol" an oxymoron?
Thanks in advance for your feedback,
Mari
My suggestion would be to re-read the Salzman study. This was a bench study done with peripheral catheter hubs, cleaning the inside with a variety of agents. This study also had concerns about the alcohol inside the lumen especially in neonates. They tested the effluent for alcohol content and found that it was not a sufficient amount to even cause harm to their babies. Also notice the date of 1993 on this study. We were not using needleless connectors at that time. In fact the FDA has only issued a hazard letter recommending their use in 1992. The only product available at that time was Interlink. I think Clave was introduced in 1993 or so. This study does focus on the hub itself. I do agree with you on our terms and the confusion between hub and connector surfaces. Alcohol will quickly flash off (dry) so the chance of actually injecting any into the vein is very small. You could also point out that the FDA cleared the SiteScrub device containing IPA for the specific purpose of cleaning inside the hub. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Perfect - very helpful. Thank you, Lynn.
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center