I need help...I have been researching past topics posted here and have found great information about heparin and flushing but I need assistance on how to properly defend the standards. I was at a meeting yesterday with the local hospital. I met w/ the CLABSI team, unit managers, home care and nursing home RNs to discuss some issues. Our goal is to improve outcomes both inpatient and in the alternate care arena. One issue was dressing changes to PICCs and the other was the fact that the hospital does not use heparin to flush their PICCs (BARD Solo). When the patient is discharged and we are contracted to provide the medication to the patient or nursing facility, our flushing protocol follows the INS Standards, specifically #45.
I have been collecting data on PICC occlusions (partial and complete) for the past 2 years. Ever since the hospital switched to the Bard SOLO, our use of CathFlo has increased significantly. Some quarters show a greater that 60% occlusion rate. I brought this up at the meeting yesterday and posed several questions to the nurses present. The main question was why the hospital does not use heparin on PICCs? I stated it was a Standard of Practice but the nurse manager in charge stated that "Standard #45 - O" states that heparin is the "preferred" lock solution but not required. This nurse stated she has seen 6 instances in her career of HIT and she never wants to see it again. This nurse manager feels that proper pulsating flushing is the key and staff need to be retaught (per manufacturer recommendation). I told her that there is no scientific research that supports the pulsating flush technique. I mentioned biofilm and the higher risk of infection. She continued to disagree with me and that is when she stated that the standard states "preferred" and I get the feeling that she is not going to change the hospital's policy and I was not going to argue with her in front of everyone.
I have some wonderful information that has been posted here, especially by Lynn Hadaway which I plan to reference. I just do not know how to convince this nurse to change her mind...may never be able to.
I think that the lack of heparin flush starts a cascade of negative effects once the patient/resident leaves the hospital and we have to deal with the consequences. We use heparin once the patient/resident leaves the hospital (unless contraindicated). Many times upon admission to the home, there is no blood return from the PICC and the "CathFlo parade" starts.
What is the best way to state that "preferred" IS the standard? I have always supported the Standards and am very passionate about postive outcomes.
Any help and words of wisdom would be greatly appreciated!!
Marianne Valentine, RN, BSN, CRNI
PharmaCare Infusion Services
Well, Thanks for the support of my work and I will reply since I am the one who worked on this standard. I will give you a couple of points.
Yes, the wording does say "preferred" and this is written as a Practice Criteria statement and not as a Standard statement. Note the consistent use of the word "shall" in the Standard section and "should" in the Practice Criteria section. The Standards statements are not ranked. So it is either a clear yes or no on these statements. The PC statements are written to provide additional guidance on meeeting the standards statements. Catheter patency and functionality is the overall goal. You have good outcome data on your catheter occlusion problems. But I can also totally understand the risks of HIT. Were these events associated with heparin lock solution? HIT is not dose-dependent and the exact rate associated with heparin locking is not known. You should point out that the O statement is supported by 7 references and has a ranking of III - the mid-range. We do have 2 randomized trials showing that heparin is needed. I would find those studies and share them with this nurse manager.
The use of pulsatile flushing is not the answer. This technique is used in the hope that it will remove biofilm and fibrin adherent to the intraluminal wall. But it does not address blood reflux at the end of the flushiing and locking procedure. This is directly related to the type of needleless connector being used. Negative displacement NC - flush, clamp, then disconnect syringe. Positive displacement NC - flush, disconnect, then clamp. Neutral NC - sequence of flushing and clamping does not matter. Doing this in the correct sequence based on the specific type of NC in use is the single most important thing that nurses can do. What type of NC is used in this facility? Are their multiple types of NCs in use? Is there a policy and procedure to address the ones in use? I would bet this practice has a large impact on your outcomes. Positive and neutral NC make the claim that saline can be used for locking and heparin is not needed. This claim is NOT supported by any clinical studies. It is based on in vitro or bench testing not on real patient outcomes! Nurses can not determine how the NC works simply by looking at it. There must be education about this. So it is this clamping sequence and not the use of pulsatile flushing that is the answer.
I strongly believe that saline for locking catheters is not the answer. But we have no alternatives at this time. See PC statement V. This leaves only heparin in the USA, other countries have alternative lock solutions. Rather than figthing a battle that you can not win with this manager, I would focus on the NC and clamping sequence issues. This probably will improve your outcomes if the nursing staff does not use the correct technique for the NC in use.
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
I thought the Bard Solo PICC was a valved PICC and specifically designed not to allow reflux. Therefore, saline only is the correct flushing protocol. I will say this though. I also use a valved PICC (not Bard) and we switched to reduce the clogged PICC problem. So far we have had pretty good results. However, the nurses need to know there is a little different feel to the flushing and aspiration that they will not be used to. The PICC has a "swinging door" so it takes a little more pressure to draw back blood. What we have done is teach the nurses to gently aspirate about 1 cc stop until you see blood then continue with normal aspiration. The reason is to give that "door" or valve a second to open. It seems to work well. Bard also recommends only flushing with saline once a week if not in use...that was the policy for the Groshung PICC's. Ah, how I miss the old days...lol
Jack Diemer, RN, BSN
Please see the Infusion Nursing Standard 45 Flusing and Locking, Practice Criteria N regarding all valved catheters. A document such as these standards or CDC or SHEA guidelines will never recommend one brand of product over another. Outcomes with valved catheter are inconclusive and conflicting as it states in this INS document. You can choose to go exclusively by the manufacturers instructions or your can choose an evidence based practice by looking at the studies that apply to the brand you are using. As far as I know, there are no studies with published outcomes for the Bard Solo PICC. 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
There is a bigger story that I think requires you to look beyond the standards if you really want to be passionate about positive outcomes. I agree that most nurses do not flush correctly. In my experience valved PICCs can be very useful if the time and effort is dedicated to teaching proper flushing technique. A quick google search can lead to some other interesting facts about Heparin usage and it's potential effect on patients .
ABSTRACT
"Heparin, known for its anticoagulant activity, is commonly used in catheter locks. Staphylococcus aureus, a versatile human and animal pathogen, is commonly associated with catheter-related bloodstream infections and has evolved a number of mechanisms through which it adheres to biotic and abiotic surfaces. We demonstrate that heparin increased biofilm formation by several S. aureus strains. Surface coverage and the kinetics of biofilm formation were stimulated, but primary attachment to the surface was not affected. Heparin increased S. aureus cell-cell interactions in a protein synthesis-dependent manner. The addition of heparin rescued biofilm formation of hla, ica, and sarA mutants. Our data further suggest that heparin stimulation of biofilm formation occurs neither through an increase in sigB activity nor through an increase in polysaccharide intracellular adhesin levels. These finding suggests that heparin stimulates S. aureus biofilm formation via a novel pathway."
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
I have not overlooked the in vitro studies on this. I am aware of at least 2 in vitro studies demonstrating that heparin encourages the growth of biofilm in the lab. There is no clinical evidence that heparin increases the risk of CRBSI though. A couple of years ago at AVA, I think issam Raad, MD spoke about this stating that no one has taken this lab data to a clinical study. Additionally, there is the systematic literature review of heparin locking solution that found there is no evidence that heparin lock has an impact of CRBSI. Many years ago, there were articles stating that heparin could reduce CRBSI due to the benzyl alcohol preservative in the heparin solution - this was wrong! So until there are clinical studies, we can not apply in vitro data collected in a lab to a clinical outcome. I accept the fact that heparin is not the ideal catheter locking solution due to the numerous issues with it. I have published several articles about these issues. However saline does not work successfully either. There are alternative lock solutions commercially available in prefilled syringes in other countries, however there are none available yet in the USA due to the requirement from the FDA about brinnging these combination products to market. So for now, heparin is the only game in town!! 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