title: Improving Care of Peripheral Intravenous Needleless Connectors
Creators: name: Slater, Karen
Publisher: name: Griffith University
Year: 2022
Subjects: subject: Decontamination
subject: Observation
subject: PIVC
subject: Hand Hygiene
subject: randomised controlled trial (RCT)

description: Background: Most hospitalised patients have a peripheral intravenous catheter (PIVC) at some point during hospitalisation. Although the rate of bloodstream infection (BSI) for PIVCs is low, the sheer number of devices inserted makes them a device of interest, since cumulatively many infections occur worldwide each year. Access to intravenous (IV) lines for the administration of medication and fluids in most of the developed world is through the needleless connector (NC) component of a PIVC. NCs were introduced several decades ago to reduce the risk of needlestick injuries amongst healthcare workers. Although they have been successful in reducing needlestick injuries, there has been an unintended consequence of NCs being associated with increased patient BSI. Patient BSI leads to prolonged length of hospital stay and higher costs, as well as significant morbidity and mortality. About half of all BSIs are attributed to the insertion process and half to on-going maintenance care. One of the most important aspects of maintenance care is NC disinfection, which should take place prior to each access of the NC. When disinfection does not occur, or is inadequate, there is a risk of microorganisms gaining access to the patient’s bloodstream. The optimal cleaning duration and disinfectant agent for NC disinfection have not been established. There have been many laboratory-based studies of NC disinfection but few in the clinical environment. Establishment of the optimal disinfectant agent and disinfection duration is vital to prevent patient BSI and improve patient outcomes. It is also important to establish current practice and identify how this compares to best practice guidelines and what factors influence clinicians’ practice behaviours, since providing evidence-based practice is vital to improve patient outcomes and decrease the risk of patient BSI.Aims and Objectives The aim of this PhD was to establish the most effective method for disinfection of PIVC NCs in the clinical environment and to examine current local infection prevention practices to improve NC care. The research findings will inform healthcare worker practice in the care of PIVC NCs to prevent BSIs. Four objectives guided the three phases of the research: 1. To determine the most effective active disinfectant agent and scrub time to disinfect NCs; 2. To establish adequate NC drying times after disinfection; 3. To evaluate current local practice of PIVC NC care; and 4. To identify nurses’ self-reported practice and attitudes regarding NC care and identify factors that influence their behaviour. Design: This PhD had a multi-method research design. It was underpinned by the Mitchell and Gardiner Infection Prevention and Control conceptual framework. This framework entails a multi-faceted approach to infection prevention. There were three phases to this research: a factorial randomised controlled trial (RCT) comparing disinfectant solutions and disinfectant times, with an associated NC drying time experimental study; an observational study to establish local PIVC care; and finally, a survey of nurses’ practice and attitudes about NC care. Phase 1, Part 1: Research questions: 1. What disinfection agent, 70% isopropyl alcohol (IPA) or 2% chlorhexidine in 70% alcohol (CHG-IPA), is more effective in eliminating microorganisms on PIVC NCs? 2. What disinfection time (5, 10, or 15 seconds) is most effective in eliminating microorganisms on PIVC NCs? Setting: Tertiary adult hospital in Brisbane, Australia. Sample: 300 NCs on PIVCs of adult in-patients located on the internal medical units. Main findings: There was no statistical difference between 70% IPA and 2% CHG in 70% IPA (p = .62) in disinfecting the external surface of NCs in the clinical environment; both were effective, but neither removed all microorganisms. There was no statistical difference in the effectiveness of 5, 10, or 15 (p = .21) second scrub times. Phase 1, Part 2 Research questions: 1. What is the effective drying time of 70% IPA, 2% CHG in 70% IPA, and 10% povidone iodine for NC disinfection? 2. Does the drying time of the three recommended disinfectants differ? Setting: Non-clinical area of tertiary adult hospital in Brisbane, Australia Sample: Three commonly available disinfectant preparation pads/wipes were compared. Main findings: The drying time of the three tested disinfectants differed substantially. After a 15-second scrub, 70% IPA was consistently dry after 5 seconds and 2% CHG in 70% IPA was consistently dry after 20 seconds. Drying time for povidone iodine 10% was not established, as it remained wet at 6 minutes, making its use clinically unfeasible. Phase 2 Research questions: 1. How often do nurses decontaminate their hands prior to accessing PIVC NCs (Moment 2 of the 5 Moments of Hand Hygiene)? 2. How often do nurses disinfect PIVC NCS prior to accessing them? 3. What is the length of time that nurses spend disinfecting PIVC NCs prior to accessing them? 4. What is the length of time that nurses let NCs dry after disinfection, prior to accessing them? Setting: Tertiary adult hospital in Brisbane, Australia Sample: 108 observations of nurses working in the emergency department, two medical wards, and two surgical wards. Main findings: Compliance with disinfection of NCs was high (99%), although disinfection time was a much shorter duration than that recommended in the hospital policy (average 6.1 seconds vs 15 seconds). Compliance with hand hygiene prior to drawing up medication (33%) and immediately prior to medication administration (43%) was suboptimal. The most common duration that nurses allowed NCs to dry was 6–10 seconds. Working in the emergency department setting and use f gloves were associated with poorer compliance with hand hygiene.Phase 3: Research questions: 1. What are nurses’ self-reported practices of NC care? 2. How do self-reported practices of NC care compare to current clinical guidelines and results from previous studies? 3. What influences nurses’ behaviour in relation to NC care and how does this compare to previous studies? Setting: Tertiary adult hospital in Brisbane, Australia Sample: Registered and Enrolled nurses working within the clinical divisions. Main findings Most nurses (89%) stated that they always disinfect NCs prior to access. Nurses’ ability to recognise and undertake the correct sequencing for clamping and line/syringe disconnection was low; 79% of nurses identified the correct clamping and disconnection for negative pressure NCs, and 34% identified the correct sequencing for positive pressure devices. Nurses’ behaviour was most influenced by other senior nurses. The risk of introducing bacteria into the patient’s bloodstream was of great concern to most nurses. Conclusion: PIVC-associated BSI, reflecting suboptimal PIVC maintenance care, remains a serious problem. The results of this PhD focusing on NC disinfection highlight that NCs in the clinical environment are frequently contaminated with microorganisms found on the skin. The RCT—the first on this topic undertaken in a clinical environment—determined that the disinfectants and timeframes tested were very effective in removing most microorganisms from NCs in the clinical environment, but there was no difference between the disinfectants or application durations trialled. The drying time study—the first to examine drying time for commonly used disinfectant preparation pads/wipes on NCs—determined that IPA had the shortest drying time. The observational study established that most nurses disinfect NCs prior to access, but for a shorter duration than is currently recommended. Hand hygiene associated with NC care was suboptimal. The survey—the first comprehensive Australian study—established significant nursing knowledge gaps in NC care and identified opportunities for improvement (particularly the sequencing of disconnecting and clamping NCs and lines), which has the potential to reduce BSIs; it also established that local senior nurses were most likely to influence behaviour. Maintenance care of PIVC NCs has previously been minimally researched and is likely the missing link in infection prevention strategies. This PhD has provided comprehensive new evidence and attention now needs to be directed toward improving the maintenance care of NCs to reduce patient BSI and improve patient safety.