Course Access
Hi Cath
I still have not seen definitive evidence that equates hub scrubbing with chlorhexidine containing swabs as being more effective than just 70% alcohol swabs for prevention of line infections.
The 2016 INS guidelines state:
F. Perform a vigorous mechanical scrub for manual disinfection of the needleless connector prior to each VAD access and allow it to dry.
1. Acceptable disinfecting agents include 70% isopropyl alcohol, iodophors (ie, povidone-iodine), or >0.5% chlorhexidine in alcohol solution. 7,16 (II)
2. Length of contact time for scrubbing and drying depends on the design of the needleless connector and the properties of the disinfecting agent. For 70% isopropyl alcohol, reported scrub times range from 5 to 60 seconds with biocide activity occurring when the solution is wet and immediately after drying. More research is needed for other agents or combinations of agents due to conflicting reports regarding the optimal scrub time. 3,17,18 (II)
3. Use vigorous mechanical scrubbing methods even when disinfecting needleless connectors with antimicrobial properties (eg, silver coatings). 19-24 (IV)
G. Use of passive disinfection caps containing disinfecting agents (eg, isopropyl alcohol) has been shown to reduce intraluminal microbial contamination and reduce the rates of central line-associated bloodstream
infection (CLABSI). Use of disinfection caps on peripheral catheters has limited evidence but should be considered.
I do agree that staff confusion is an issue, so one product should be selected and made available. But until I see credible evidence to support use of chlorhexidine containing swabs on hubs, I will continue to promote 70% alcohol ‘scrub the hub’.
My opinion, anyway.
Cheers
Michael
Michael Wishart, CICP-E
Infection Control Coordinator
A 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
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Hi All,
Agree with Cath.
Historically we stocked both 70% alcohol & the alcohol 2% CHG swabs / solution in clinical areas
After reviewing & auditing accessing devices it became quite clear that staff were confused about what to scrub the hub with or for insertion of a PIVC etc.
There was a lack of standardisation amongst staff about what product to use on which vascular access device when asked,
More frighteningly, staff also often referred to swabs according to the colour of the packet not the antiseptic solution – ‘use the blue swabs’ / ‘use the pink swabs’ / ‘use the orange swabs’.
To further complicate things – the colours of the swab packets can change depending on the supplier of the product. & at one point the alcohol swabs were virtually the same colour as the CHG swabs.
Chinese whispers were also a problem as some staff had heard about CHG sensitivity either in a journal, TV, Dr Google or at a conference & were taking it upon themselves & influencing others to use alcohol only which was not procedure.
Using a risk management approach – 1st rule of thumb Eliminate!
The decision was made by the LHF to remove the alcohol swabs from all patient units & only stock alcohol CHG unless the clinical area identified a specific need for just alcohol swabs.
The risk of infection due to staff not using the correct antisepsis solution to scrub the hub or insertion far out-weighs the sensitivity issue for CHG.
Cheers
Catherine Wade
Clinical Nurse Consultant | Infection Prevention & Control (IPAC)
Level 1 / 67 Holden Street, GOSFORD NSW 2250
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Dear Daniella
I recently reviewed evidence and guidelines for best practice with vascular access devices. Below are the recommendations I made on based on the review and the supporting references.
I have never understood Australia’s reluctance to adopt scrub the hub campaigns and lack of interest in routine use of protective IV caps. As a recently hospitalised and immunosuppressed patient I worried every time my line was accessed as there was nothing uniform in any of the accesses. There are now good Australian research papers showing risk with even simple peripheral vascular catheters. IVs are inserted very commonly making them one of the most frequent infection risks in acute care settings.
With regard to CHG I also note a general reluctance to its use in Australia as evidenced by poor recommendations in the draft NHMRC IC Guidelines, questions raised previously on this discussion forum and at ACIPC meetings. Personally I disagree with Michael’s earlier comment given that it is often a long time between accesses of IV lines and if oncovered they can easily become contaminated hence an agent containing alcohol and CHG is safe to use in non CHG-sensitive populations and it gives immediacy plus residual. As you would appreciate CHG has been used extensively in healthcare and domestic settings for decades. True CHG sensitivity is extremely rare. Anaphylaxis reports typically demonstrate multi-site simultaneous exposure to CHG ie surgical skin prep + use of CHG lubricant jelly + CHG impregnated CVC insertion. The NHMRC’s recommendation that we keep risk registries of CHG containing products is salient as is the recommendation to take adequate histories from patients regarding sensitivities.
In a recent report where he considered “resistance” Kampf argued that we should use CHG cautiously and perhaps even in a stewardship way. He was smart to recognise that there is no universal agreed definition of CHG-resistance and that the mechanisms are very different to antimicrobial resistance.
I expect many will disagree with my views but I am very happy that CHG was used extensively to help prevent infection in my recent surgery and hospitalisation. I would have warmly welcomed the use of routine CHG & alcohol hub disinfection.
Recommendations based on literature and guideline review.
Care must be taken not to contaminate the lines when accessing lines and their administration sets.1,65,72
A single patient use application of 70% alcohol alone1,73 or >0.5% chlorhexidine in 70% alcohol1,10,29,72 should be used70 for 529- 15 seconds1,10,73 and allowed to dry when decontaminating the catheter hub or injection ports prior to every access of the circuit. This includes every time an infusion set is added or removed, as well as administration of medication.10,65 Supplies for disinfecting should be kept at the bedside.1
Use of disinfection caps on peripheral and central catheters should be considered.1,72
1. Gorski LA, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;39(1S):1-256.
10. Loveday HP, Wilson JA, Pratt RJ, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2014;86 Suppl 1:S1-70.
29. Marschall J, Mermel LA, Fakih M, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(7):753-771.
65. Society. AaNZIC. Central Line Insertion and Maintenance Guideline. 2012; http://www.anzics.com.au/Downloads/ANZICS_Insertion%26maintenance_guideline2012_04.pdf, 2017.
70. Ling ML, Apisarnthanarak A, Jaggi N, et al. APSIC guide for prevention of Central Line Associated Bloodstream Infections (CLABSI). Antimicrob Resist Infect Control Antimicrobial Resistance & Infection Control. 2016;5(1).
72. Nursing. RCo. Standards for infusion therapy. London.: Royal College of Nursing.; 2016.
73. (INICC). INICC. International Nosocomial Infection Control Consortium (INICC) Bundle to Prevent Central Line Associated Bloodstream Infections (CLAB) in Intensive Care Units (ICU): An International Perspective. Argentina.2017.
Cath
Cathryn Murphy RN B. Photog MPH CIC FAPIC FSHEA CICP-E PhD
Chief Executive Officer & Creative Director
Infection Control Plus Pty Ltd
Adjunct Associate Professor
Faculty of Health Sciences and Medicine, Bond University
QLD, Australia
E: Cath@infectioncontrolplus.com.au
M: +61 428 154154
W:http://www.infectioncontrolplus.com.au
Dear colleagues,
I am interested to know if Australian hospitals are routinely using wipes containing chlorhexidine 2% with alcohol 70% to disinfect vascular access hubs (i.e. to ‘scrub the hub’). In particular, is this practised on general wards when accessing a PIVC?
Many thanks,
Daniela
Daniela Karanfilovska
Clinical Nurse Consultant
Infection Prevention & Healthcare Epidemiology
t 03 90762819 m 0427 703 769
e D.Karanfilovska@alfred.org.au
Alfred Health
55 Commercial Road
Melbourne VIC 3004
PO Box 315 Prahran
VIC 3181 Australia
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