We have seen a rise in infections this year with patients having implanted ports. Currently I am looking at our practice related to TPN as each patient was receiving TPN (freamine for 24 hours, lipids for 12 hours). We primarily use a single lumen needle (have a y-sited needle for non-power injectable ports), needleless connector, and then our TPN tubings. We connect the lipids below the freamine filter.
Our protocol is to flush with 10 ml of NS before and 20ml of NS after lipids, so if the tubing is disconnected from the needleless connector for a blood specimen and then reconnected this is what is followed.
The lipid set is disconnected and thrown out after the 12 hours is finished. The freamine set is changed every 24 hours. Should we be changing the needleless connector every 24 hours with the tubing?
I have also recently found that nursing staff is using the available y-site on the freamine tubing (where the lipids were connected) to push IV meds (flushing before and after with saline).
Do you change the needleless connector with the freamine tubing? We use a neutral connector with a straight fluid pathway. Any other thoughts? The organisms have been staph epi and staph aureus.
When are this infection occuring after port insertion? Newly implanted or been in situ for several weeks or months? The latter could be from previous uses introducing organisms that led to biofilm. Now the increased fluid flow and flushing is causing biofilm breakage and BSI.
IV fat emulsion is specifically known for fungal infections. All IV sets exposed to IVFE is recommended to be changed at least every 24 hours, however PN sets that have not been exposed to IVFE can remain in use for 96 hours.
All sets used for PN and IVFE should not be used for any other fluids or medications. This is for both infection prevention and solution compatibility reasons.
If this is a continuous infusion, why do you even have a needleless connector in the line. I would get it out and remove one possible cause.
All staph organisms suggest this is a skin organism and very common. Hand hygiene? Use of gloves? Management of the male luer end of the set while it is disconnected for blood draws? I would also stop this as a routine practice and evaluate each patient as to the ability to draw blood from a peripheral site. I would prevent this set disconnection totally. 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
When you say "so if the tubing is disconnected from the needleless connector for a blood specimen and then reconnected this is what is followed" are you connecting the same tubing after the blood sampling or a new on? Just wondering how you are protecting the end during the process and if that may be the source of infection? Valorie
Valorie Dunn,BSN, RN, CRNI, PLNC
These are not new ports and the patients have developed the infection after 30 days up to 3 months of being in the hospital. The only thing consistent between them is they do not have adequate peripheral access for phlebotomy and/or low platelet counts and were receiving TPN (freamine/lipids).
As far as how is the male tip of the tubing is maintained during a blood draw....I know this has been mentioned before in this forum. The tip from the prefilled syringe is applied to the male leur and this has been our practice since we converted to these syringes and were given this info from the sales rep./educators. Now this was 5 years ago. Why would we suddenly be seeing this as a source? My feeling is it is something else like using the line to give IV pushes through or the lack of adequate scrubbing.
What are others doing at large oncology units when other meds must be given or blood must be drawn? Having peripheral access would be a great option but is not realistic for all patients. If we were to use a bifurcated extension set my understanding is we would need to change the set every 24 hours as well.
Using that syringe tip cap is an off-label use. I am not saying that this is the problem, but I am saying that your decision to use this cap to apply to the male luer of the IV set is not recommended by any of the prefilled syringe manufacturers. If you were verbally told by any company rep that this was acceptable, they were wrong! These are labeled as a one time use product, which means once it is removed from the syringe it goes in the trash. Did you get this practice in writing from the manufacturer? If not, this could be a serious issue if any of these infections lead to a lawsuit.
You are correct that the bifurcated extension set would need to be changed q 24 h if it is exposed to IVFE.
I suspect these infections are not caused by anything your staff is or is not doing since these ports have been indwelling for so long. Previous uses have introduced organisms which created the biofilm. Now the port is subjected to more frequent and larger volumes of flushing and fluid flow. This is causing that biofilm clusters or clumps to break off, and this is producing the BSI.
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