Hello all,
Our PICC insertion trays are packaged with an outer blue wrap, small towel on top, then the sterile gown. Just below that is the second blue wrap. Those with two inserters per team put on the gown and then gloves, and open the second blue wrap. The second team member drops the needleless connector, BioPatch and sterile saline into the tray area. Some of the single inserters lift the gown by the corners and move it to the side, open the second blue wrap, and drop items into the middle, and then put on the sterile gown and gloves and finish setting up the tray. Some of the single inserters drop items onto the first blue drape, then gown and glove, and then open the second blue drape. We then pick up the items before opening the last flap, and move them into the center of the tray and finish the setup. No one is putting anything on the very 1 inch edge (margin of safety) and no one feels that sterility has been breached with either method.
Our vascular access services group was just told that we do not follow best practice the way we are setting up our trays. We are told that we must open the first drape, put on gown and gloves, open the second drape. Then touch and drop the non-sterile items into the center, along with another sterile gown and gloves. Then degown and deglove, and then regown and reglove with the new sterile gown and gloves, and then proceed. They said there is an expert source and we will all do this from now on.
Questions: is our procedure incorrect? Are we compromising sterile technique? Is there a better way? Is the double-gown technique described above a better way? Did I describe this enough so everyone can understand?
I am all for doing best practice but this doesn't make much sense to me. I looked up the OR standards: Principle #4 "All items introduced onto a sterile field should be opened, dispensed, and transferred by methods that maintain sterility and integrity." I believe we are all doing this and would appreciate any feedback.
Thank you,
Carole
Hello,
Clarifying my question:
Does anyone who inserts PICCs as a single inserter put on a sterile gown two times, once during set up and again before starting the procedure?
Thanks,
Carole
Our PICC kits are packaged from Bard and do not even have 2 sterile gowns in them. I do however take an extra pair of sterile gloves in to use during insertion. Your kit sounds more like the kits we used when our sterilization department was providing the towels but we still did not sterile gown twice. First set of gloves to get the main sterile packages open and draped across table and to get our sterile chlorapreps and sterile gown onto sterile area. Open and drop other items onto sterile field at arms length. Then I proceed to get rid of first sterile gloves, put sterile gown and new sterile gloves on. I do have my gown on when I prime the PICC and situate things on the field. Our facility does about 1100-1200 PICCs/yearly with no line infections associated with insertion.. Hope this helps.
Paula C RNBC,CRNI
Intravenous Resource Nurse
Paula Campbell RNBC, CRNI
Intravenous Resource Nurse
Carole,
I insert PICCs as a single inserter. I do not gown twice. I have been placing PICCs for 8 years without a single insertion infection. We use Bard's standard complete kit and add our own Needle Guide kit, Bio Patch, infusion caps, extra sterile flush and 1 more CHG scrub.
My routine.
My had is usually on when I come into the room. Usual handwashing and gloving for ultrasound of arm/s and measurements. 1 scrub with CHG just for general cleaning since I don't have the luxury of having someone to come bathe arms.
Wash hands. Open kit. Placing contents on my sanitized table. Carefully move the top section (If I can set it on a cooperative patients legs I will, see comments later) and set it aside & open 3/4 of the way leaving contents covered with last corner. Carefully pick up glove kit and move to my sanitized table that is arranged with items to be dropped. Pick up bottom kit and drop what is left on top into the area protected by the corner of the top section so these items remain sterile (I lift the corner and drop items and lay it back down with the corner still folded back as it originally was). Pull out tourniquet, apply clean gloves and place on pt's arm (very lightly tie w/o constricting if possible to keep it in place, I wish they would give us longer tourniquets). Apply Shelock and ECG leads on patient.
Mask on if not already. Wash hands. Open PICC kit section. Carefully drop the extra items I need onto my sterile field previously arranged on my other clean table. I add an extra CHG scrub to other items I need that are not in the kit.
Wash hands. Note that I have now washed my hands at least 4 times. Depending on what else I did before starting assessments it might be even more. Now fully open the top kit that now has the gown, small sterile drape and CHG scrubs. Lift gown away from other items by its corner which leaves these other items sterile on the sterile field. Gown by baby bib method without touching my hands to my neck or cap, lean forward and sweep my arms in and forward without touching myself and use sterile technique to don the gloves from the kit. Pick up my drape and scrubs and add them to my sterile field. Assemble my kit. Even during assembly I do not touch anything that doesn't have to be touched. For instance. I pick up the th infusion cap by its side and attach the syringe, then pick up the hub end of the picc without touching the hub end, screw the 2 together and flush.
I am right handed. With my left hand I hold the patients hand keeping my sleeve up. Scrub their arm and with my right hand pick up the small sterile drape and place it under their arm. Tie the tourniquet. (if the patient is one who is cooperative I will lay the small sterile kit on their legs and work from there. Sometimes depending on the size of the patient and situation I like to pull that 99% still sterile drape as only the corners have been touched up to where I need to stand to help protect my gown as I am short. The corner is hanging way down off the bed. I do this with my left hand just before I pick up the patients hand)
I change to long cuffed surgical gloves. These will pull up almost to my elbow and cover anything that might have accidentally touched the patient in that last moment.
Drape the patient with the drape from the kit and window the site. If the pt has a very rounded chest/abdomen, I will make a pocket fold on my side and secure with a piece of tape. This insures that I have a sterile area between me and the patient and things won't roll off to my chest. Scrub one more time with the tinted CHG scrub. While it is drying I cover my probe and get it ready for insertion. By then all CHG should be fully dry.
When insertion is complete I clean any blood from skin with my last CHG scrub and use it to loosen the adhesive from the drape. That makes life much easier on fragile skin. Finish securing and done.
One other thing to add: I had the lovely experience of getting to be the nurse to get the surprise evaluation of my PICC insertion by the Joint Commission or the state, I don't remember now which one it was. That time there was a ton of observers to watch sterile technique. They had no complaints and only two questions. The two questions were. Why don't you tie your gown and why don't you wash your hands between sterile glove changes. They were satisfied with my answers. I replied. This is not an OR so I do not have to be OR sterile. This is a procedure and the back of me is not considered sterile so the gown does not have to be tied. The rooms are not set up for washing hands after sterile gowning and since I am going from sterile glove to sterile glove there would be more risk of contamination of my sterile gown to attempt another handwash and dry with non sterile paper towels.
I do keep handy a bottle of special pump alcohol that the hospital supplies for my sensitive skin. I have to use even it sparingly because even it will make my skin crack and bleed. If I am doing a very difficult picc and start to worry about my gloves or have to get supplies and reglove, I can reach it and alcohol my hands. But otherwise I must stick with handwashing. In the winter I put on skin prep on the back of my hands every morning after I wash my hands for the first time. I found it helps keep my skin intact.
We have had insertion infections from centrally placed CVCs and Dialysis catheters. I don't observe those insertions so I can't comment. I will stand by 8 years and counting sucessful insertions even on patients with terrible infections, MRSA, C-diff and now a couple of the newest ones I am going blank on. Would I like to have some one with me? You bet I would. But that isn't going to happen. My team was just downsized to just me. I spoke to my supervisor that I learned that hospitals are getting dinged for not having a trained observer to watch PICC insertions. The comment, "we'll deal with that when that day comes". I will stay with carefull cleaning of my equipment before and after each use, organization of my supplies both for dropping and organization on my sterile field. Lots of hand washing and lots of CHG scrubs to my success.
Mary Penn RN VA-BC
St Charles, MO
Carole,
Who told you, you were doing it wrong? So many experts yet no evidence to HOW they became experts. Picking up the gown at the corners is fine. If you notice the gown is folded so that the part exposed to you is the part against your body...If you were taught your technique by a reputable "master" at PICC placement...chances are your doing it right.