Timothy Royer, BSN, CRNI, Nurse Manager / IV Team – Retired 2009

1. Implementing a Better Bundle in the Adult Population to AttainZero Central Line Associated Blood Stream Infections:A Prospective Surveillance Timothy Royer, BSN, CRNI, Nurse Manager / IV Team – Retired 2009 VA Puget Sound Health Care System, Seattle, Washington

2. Financial Disclosures • Nurse Consultant for: • Genentech – Cathflo Nurse Trainer • Medegen – Clinical Practice Consultant • Ethicon – Speaker’s Bureau The studies presented herein were completed independently, without financial support, input, or influence from any manufacturer or commercial entity. Timothy Royer, RN, BNS, CRNI

3. Objectives of this Presentation • 1. Discuss 4 components of the central line bundle • 2. Discuss strategies to implement the central line bundle Timothy Royer, RN, BNS, CRNI

4. Topics Covered • 1. National Patient Safety Goals (NPSG)s • 2. IHI Guidelines/Recommendations • 3. Components of the central line bundle • 4. Additional components to add to the central line bundle • 5. Implementing the central line bundle • 6. Strategies for implementing the central line bundle • 7. Measuring outcomes of the central line bundle Timothy Royer, RN, BNS, CRNI

5. NPSG • VII. Goal 7 – Reduce the risk of health care –associated infections. • A. Meeting Hand Hygiene Guidelines (NPSG.07.01.01) • B. Not applicable to hospitals • C. Preventing Multidrug-Resistant Organism Infections (NPSG.07.03.01) • D. Preventing Central Line–Associated Blood Stream Infections (NPSG.07.04.01) • E. Preventing Surgical Site Infections (NPSG.07.05.01) http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/ Timothy Royer, RN, BNS, CRNI

6. IHI • The central line bundle has five key components: • Hand hygiene • Maximal barrier precautions • Chlorhexidine skin antisepsis • Optimal catheter site selection, with avoidance of using the femoral vein for central venous access in adult patients • Daily review of line necessity, with prompt removal of unnecessary lines http://www.ihi.org/nr/rdonlyres/0ad706aa-0e76-457b-a4b0-78c31a5172d8/0/centrallineinfectionshowtoguide.doc Timothy Royer, RN, BNS, CRNI

7. Standards of Practice • Besides looking at the NPSG, IHI, CDC Guidelines, and the Draft of the new CDC “Guidelines for the Prevention of Intravascular Catheter-Related Infections” we need to be guided in our practice with the “Infusion Nursing Standards of Practice”. Your Standards of Practice should look well used too. Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs. 2006;29(1S) Timothy Royer, RN, BNS, CRNI

8. What Do We Do?? • Protect the patient from the central venous catheter. • Extraluminal causes for infection • Intraluminal causes for infection • How do we get there? • Device selection • Care and Maintenance • Staff and patient education • Specialized Teams (IV Teams, Vascular Access Teams) • What does it really boil down to? Finding evidence and using critical thinking to make the right choices Timothy Royer, RN, BNS, CRNI

9. Do we ever say, “That’s the way we have always done it”? Just Asking Timothy Royer, RN, BNS, CRNI

10. Where Evidence Points Timothy Royer, RN, BNS, CRNI

11. Maximum Barrier Precautions • For the operator placing the central line and for those assisting in the procedure, maximal barrier precautions means strict compliance with hand hygiene and wearing a cap, mask, sterile gown, and sterile gloves. • Include maximal barrier precautions as part of your checklist for central line placement. • Means covering the patient from head to toe with a sterile drape, with a small opening for the site of insertion. • Using a checklist and empowering nurses to stop the procedure if sterile technique is broken. Timothy Royer, RN, BNS, CRNI

12. Removal of Unnecessary Lines • Include daily review of line necessity as part of your multidisciplinary rounds. • State the line day during rounds to remind all as to how long the line has been in, e.g., “Today is line day 6.” • Include assessment for removal of central lines as part of your daily goal sheets. • Record time and date of line placement for record-keeping purposes and evaluation by staff to aid in decision making. • Define an appropriate timeframe for regular review of necessity, such as weekly, when central lines are placed for long-term use (e.g., chemotherapy, extended antibiotic administration, etc.). • Daily review was designed for the intensive care population and may not be appropriate when long-term use over weeks or months is planned. No, it is not OK to say “Just in Case…” Timothy Royer, RN, BNS, CRNI

13. Evidence on Removal of Unnecessary Lines • Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-32 • Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32:2014-20 Timothy Royer, RN, BNS, CRNI

14. Background for the Studies • It is the goal of every infusion nurse and facility to have a zero Central Line Associated Blood Stream Infection (CLA-BSI) rate to prevent: • Morbidity • Mortality • Excess cost of care • The central line bundle is a good start for insertion, we were looking for improvement and added additional items to come up with a Central Line Care and Maintenance Bundle (CLC&M Bundle) Timothy Royer, RN, BNS, CRNI

15. Building a Better Care BundleWhat We Did • June 2003 - Change to swabable positive displacement valve • January 2005 – Maximal sterile barriers & CHG prep • July 2006 - Chlorhexidine Gluconate (CHG) impregnated disk, increase use of PICCs in place of centrally inserted central catheters (CICVC), and a vigorous care and maintenance education program • January 2007 – Started clear version of the same valve, as a cue, coupled with continuous Medical Center ”Scrub the Hub and Flushing with 20mls. of normal saline” campaign. Timothy Royer, RN, BNS, CRNI

16. Infection Rate Run Chart Timothy Royer, RN, BNS, CRNI

17. Rationale Behind the Additions to theCLC&M Bundle Timothy Royer, RN, BNS, CRNI

18. Evidence & Logic for Additions • Evidence and critical thinking that was used reduce Central line Associated Blood Stream Infections (CLABSI) (some newer references also cited): • Specialized trained staff for central venous catheters IV Teams • Swabable needleless connectors allow for a greater reduction of bacteria colony counts on devices • Clots form a tighter matrix when precipitates are present in the lumen in the catheter • Central venous catheters with clots are at higher risk for infection • Positive displacement valves prevent blood from backing up the catheter on syringe removal Timothy Royer, RN, BNS, CRNI

19. Evidence & Logic for Additionscontinued • Prevention and/or early decloting of catheters reduces the risk of infection • Switching to saline locks from heparin • Using manufactured securement devices reduces infection risk • Education on CVC care improves patient outcomes including reducing CLA-BSI • Peripherally Inserted Central Catheters (PICC) have a lower infection risk • Chlorhexidine (CHG) eluting disk or dressings provide an environment to keep colony counts low around insertion site • Clear housing for needleless connectors Timothy Royer, RN, BNS, CRNI

20. IV Teams / PICC Teams /Vascular Access Teams • Not PICC Stick and Run teams or teams that perform venipunture well. • Coordinate with Infectious Disease (Infection Preventionists) and Physician Directors of Departments. • Very active participants in the Care and Maintenance of CVCs • Educate nurses on best practices • Using vigilance to ensure best nursing care and practices are sustained • Provide additional training and education when new practices or products are implemented • They should be active within committees • Infectious Disease • Disposable Equipment Committee (DEC) • Nurse Practice Committee (NPC) • Facility Education Department • Equipment Committee • Pharmacy and Therapeutic Committee Timothy Royer, RN, BNS, CRNI

21. IV Teams / PICC Teams /Vascular Access Teams • Bring in new vascular access products • TheSteps • Review new product • Self testing the devices • Will it work? • Does it work like they say it does? • Where is the evidence? • Manufacturer generated? • What level of research? • Does it make sense? • Talk to your colleagues in different facilities • Talk with the manufacturers’ engineers • Talk with your own facility medical equipment engineers Timothy Royer, RN, BNS, CRNI

22. IV Teams / PICC Teams /Vascular Access Teams • Clinical Evaluation • Involve all members of the Team • Specialized Teams • Unit Managers and staff • Disposable Equipment Committee • Make the right choice for the patient. • Present to the NPC and DEC • Now the real hard work begins Timothy Royer, RN, BNS, CRNI

23. IV Teams / PICC Teams /Vascular Access Teams • Staff education • Pre-educate the whole hospital on the new product coming in. • Be part of the education on the product. • Competencies • Gathering Data with the CICs • Initiating practice change • Research – whether actual or reading and implementing change. Timothy Royer, RN, BNS, CRNI

24. Draft of CDC GuidelinesReferences for having “IV Teams” • Nehme AE. Nutritional support of the hospitalized patient. The team concept. JAMA 1980;243:1906-8 • Soifer NE, Borzak S, Edlin BR and Weinstein RA. Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized controlled trial. Arch Intern Med 1998;158:473-7 • Tomford JW, Hershey CO, McLaren CE, Porter DK and Cohen DI. Intravenous therapy team and peripheral venous catheter-associated complications. A prospective controlled study. Arch Intern Med 1984;144:1191-4 • Scalley RD, Van CS and Cochran RS. The impact of an i.v. team on the occurrence of intravenous-related phlebitis. A 30-month study. J Intraven Nurs 1992;15:100-9 • Palefski SS, Stoddard GJ. The infusion nurse and patient complication rates of peripheral-short catheters. A prospective evaluation. J Intraven Nurs 2001;24:113-23 • Miller JM, Goetz AM, Squier C and Muder RR. Reduction in nosocomial intravenous device-related bacteremias after institution of an intravenous therapy team. J Intraven Nurs 1996;19:103-6 • Hunter MR. Development of a Vascular Access Team in an acute care setting. J Infus Nurs 2003;26:86-91 • Hawes ML. A proactive approach to combating venous depletion in the hospital setting. J Infus Nurs 2007;30:33-44 • Brunelle D. Impact of a dedicated infusion therapy team on the reduction of catheter-related nosocomial infections. J Infus Nurs 2003;26:362-6 • Bosma TL, Jewesson PJ. An infusion program resource nurse consult service: our experience in a major Canadian teaching hospital. J Infus Nurs 2002;25:310-5 • Pierce CA, Baker JJ. A nursing process model: quantifying infusion therapy resource consumption. J Infus Nurs 2004;27:232-44 Timothy Royer, RN, BNS, CRNI

25. Swabable Needleless Connectors Hadaway L, Richardson D. Needleless connectors: A primer on terminology. Journal of Infusion Nursing. 2010, Vol. 33:1. • Hadaway L, Richardson D. Needleless connectors? A primer on terminology. Journal of Infusion Nursing. 2010, Vol. 33:1 • The configuration of the external connection surface can have a direct impact on the outcome with the device. • The surface design is thought to be one factor in the controversy over the infection risk associated with each device. • Needleless connectors with smooth contours, no valleys, no crevices, and no hidden pockets have the easiest surfaces to disinfect. • When we made the switch in June 2003, little evidence was out there but it made good sense. This applies to all vascular access device not just central Timothy Royer, RN, BNS, CRNI

26. Investigation on clear valves removed from patients Precipitates and Clots • Hardy • Suggests that a significant portion of clot occlusions seen in practice may be caused by many factors, including drug precipitates. • States a more tense fibrin matrix forms around the drug precipitates which leads to the formation of occlusions. • A clear needleless connector allows nurses to see if appropriate flushing was performed and if not, to continue flushing or change valve for improved outcomes • The photo illustrates an improperly flushed valve removed from a patient Hardy G, Ball P. Clogbusting: time for a concerted approach to catheter occlusions? Current Opinion in Clinical Nutrition and Metabolic Care. 2005, 8:277–283 Timothy Royer, RN, BNS, CRNI

27. Clots and Infection • We have known about the association of clots and infection for a long time: • Timsit J, Farkas J, et al. Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis. Chest 1998; 114;207-213. • Raad et al. The relationship between the thrombotic and infectious complications of CVC. JAMA 1994. • Stillman et al. Etiology of Catheter-associated sepsis: correlation with thrombogenicity. Arch Surg 1977 Timothy Royer, RN, BNS, CRNI

28. Saline Instead of Heparin • Evidence shows that heparin stimulates biofilm formation. • Shanks, Robert M. Q. et al Heparin Stimulates Staphylococcus aureus Biofilm Formation. Infection and Immunity. August 2005 p. 4596-4606 doe: 10.1128/1AL.73.8.4596-4606.2005 • Costello JM, et. al. Systematic Intervention to Reduce Central Line–Associated Bloodstream Infection Rates in a Pediatric Cardiac Intensive Care Unit. Pediatrics. Vol. 121 No. 5 May 2008, pp. 915-923. Timothy Royer, RN, BNS, CRNI

29. Saline Instead of Heparin • Research has demonstrated a correlation between catheter intraluminal biofilm formation and catheter-related bloodstream infection. • Andes D, et al. Development and Characterization of an In Vivo Central Venous Catheter Candida albicans Biofilm Model. Infection and Immunity, October 2004, p. 6023-6031, Vol. 72, No. 10. • “Recent estimates suggest that the majority of hospital-acquired infections are biofilm associated.” • Donlan, R. M. 2001. Biofilm formation: a clinically relevant microbiological process. Clin. Infect. Dis. 33:1387-1392. • Licking, E. 1999. Getting a grip on bacterial slime. Business Week, 13 September 1999, p. 98-100. • Potera, C. 1999. Forging a link between biofilms and disease. Science 283:1837-1838. • So, why are we using Heparin that stimulates Biofilm formation that is associated with Blood stream infections? Just Asking Timothy Royer, RN, BNS, CRNI

30. Prevention of clots • Positive displacement valves decrease the risk of occlusion: • Jacobs BR, et al. Central venous catheter occlusions: A prospective, controlled trial examining the impact of a positive-pressure valve device. J. of Parenteral and Enteral Nutrition. 2004; 28:2 113-118. • Rummel M, Donnelly P, Fortenbaugh C. Clinical evaluation of a positive pressure device to prevent central venous catheter occlusion: Results of a pilot study. Clinical Journal of Oncology Nursing. 2001, 5, (6), 261-265. • Feehery, Patricia A. RN, BS, CRNI, et al. Flushing 101, Journal of Vascular Devices, Summer 2003. Timothy Royer, RN, BNS, CRNI

31. Proactive Approach to Occlusion • Because Evidence shows that clots are associated with infection: • Prevent clotting of catheters • Proper flushing • Draft of the Guidelines for the Prevention of Intravascular Catheter-Related Infections: Exterior Housing of needleless connectors “inadequate flushing of the device due to poorvisualization of the fluid flow pathway in opaque devices”. • INS Standard 35: INS Standard 35: Injection and Access Caps: “If the integrity of the injection or access cap is compromised or if residual blood remains within the cap, it should be replaced immediately and consideration should be given to changing the catheter and administration set.” • Care and maintenance and proper tip placement • CVC with tips in a proximal position were 16 times more likely to have thrombosis than those in a distal position. • Cadman et al. To clot or not to clot? That is the question in central venous catheters. Clinical Radiology, 59;4:349-355. April 2004 Timothy Royer, RN, BNS, CRNI

32. Proactive Approach to Occlusion • Quick resolution of occluded catheter • *Declot early with any signs of sluggish or non-aspirating CVCs • No tying or taping off of occluded lines We are not taping off lumens with occlusions, are we? Just Asking *Deitcher SR, Fesen MR, Kiproff PM, et al, for the Cardiovascular Thrombolytic to Open Occluded Lines-2 Investigators. Safety and efficacy of alteplase for restoring function in occluded central venous catheters: results of the Cardiovascular Thrombolytic to Open Occluded Lines trial. J Clin Oncol. 2002;20:317-324. Blaney M, Shen V, Kerner JA, for the CAPS Investigators. Alteplase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm study (the Cathflo Activase Pediatric Study). J Vasc Interv Radiol. 2006;17:1745-1751. Timothy Royer, RN, BNS, CRNI

33. Non-suture CVC Securement • Citation used in the draft of the new CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections - Catheter securement devices. Lines 555-556 • “Sutureless securement devices avoid disruption around the catheter entry site and may decrease the degree of bacterial colonization.” • Yamamoto AJ, Solomon JA, Soulen MC, et al. Sutureless securement device reduces complications of peripherally inserted central venous catheters. J Vasc Interv Radiol 2002;13:77-81 • INS Standards of Practice: Standard 43. Catheter Stabilization. • “Whenever feasible using a manufactured catheter stabilization device is preferred.” • Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs. 2006;29(1S): S44. Timothy Royer, RN, BNS, CRNI

34. Staff Education on CVC Care • Reducing CLA-BSIs with staff education • Costello study (2008) • Interventions involving staff education, increased awareness, and practice changes led to decreased rates • Garcia study (2007) • An extensive education program led to better adherence to proper infection control practices • Safdar study (2008) • “The implementation of educational interventions may reduce HCAI considerably” Costello JM, et. al. Systematic Intervention to Reduce Central Line–Associated Bloodstream Infection Rates in a Pediatric Cardiac Intensive Care Unit. Pediatrics, Vol. 121 No. 5 May 2008, pp. 915-923. Garcia R, Jendresky L. A study of the effects on bacteremia and sharps injury rates after introduction of an advanced luer activated device (LAD) for intravascular access in a large hospital setting. American Journal of Infection Control, June 2007, Vol 35, Issue 5 E75. Safdar N, Abad C. Educational interventions for prevention of healthcare-associated infection: a systematic review. Crit Care Med. 2008 36(3): 933-940. Timothy Royer, RN, BNS, CRNI

35. PICCs in ICUs have a Lower Infection Rate • As noted in this facility’s Run Chart. Timothy Royer, RN, BNS, CRNI

36. Other Hospital (Med/Surg ICU) Data • *Poster Presentation “Early Use of PICCs is Associated with Decreased Catheter-Related Blood Stream Infections” *Study from the Mayo Clinic Poster Presented at the 32nd Critical Care Congress of the Society of Critical Care Medicine as a Poster Abstract. Patel, B: 2003 Timothy Royer, RN, BNS, CRNI

37. Chlorhexidine (CHG eluting disk) • Why are we worried about extraluminally? • Most noncuffed CVCs BSIs were extraluminally acquired and derived from cutaneous microflora. • Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Intensive Care Med. 2004 Jan;30(1):62-72. • More evidence that supports: • Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Intensive Care Med. 2004 Jan;30(1):62-72. • Levy I, et al. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. Pediatr Infect Dis J. 2005 Aug:24(8);676-9. Timothy Royer, RN, BNS, CRNI

38. More Evidence on CHG disk • Chambers ST, et al. Reduction of exit-site infections of tunneled intravascular catheters among neutropenic patients by sustained-release chlorhexidine dressings: results from a prospective randomized controlled rial. Hosp. Infect. 2005. 61:53-61. • Garland JS, e al. Local reactions to a chlorhexidine gluconate-impregnated antimicrobial dressing in very low birth weight infants. Pediarics. Jun;107(6):1431-6. • Roberts B, Cheung D. Biopatch-a new concept in antimicrobial dressings for invasive device. Aust Crit Care. 1998 Mar;11(1):16-19. • Fauerbach LL, et al. Continuing evolution of multidisciplinary approach to prevention of central line-associated bacteremias. AJIC. May 2004;(32)3. • Maki DG, et al. Prospective, randomized, investigator-masked trial of a novel chlorhexidine-impregnated disk on central venous and arterial catheters. Infect Cont Hosp Epidemiol. 2000 Feb;21(2):96. Timothy Royer, RN, BNS, CRNI

39. Recently Published CHG Impregnated Sponges Clinical Evidence Timsit, J, Schwebel C, Bouadma L, et al. Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults: A Randomized Controlled Trial. JAMA. 2009; 301(12):1231-1241 (doi: 10.1001/jama.2009.376 Conclusions: In this study use of Chlorhexidine-Impregnated Sponges decreased the rates of catheter-related blood stream infection by 76 %. Timothy Royer, RN, BNS, CRNI

40. Dressings with CHG Gel Pads • Evidence is very limited right now. • Below are Posters presented at the Association for Vascular Access Conference 2009 in Las Vegas, NV. • Effect of Tegaderm Chlorhexidine Gluconate (CHG) Gel Dressing on Adult Central Venous Line Related Primary Bloodstream infections. Mary E. Reilly, RN, BSN. Decreased CLABSI from 2.1 to 0.7. • Chlorhexidine Gluconate (CHG) at Central Line Insertion Sites: Disc vs. Gel Pad Tegaderm. Pat Catudal, RN and Susanne Meninger, RN. Rates stayed the same, but “ease of use” was factor in selecting this product. • USE OF AN ANTIMICROBIAL IV DRESSING WITH A MAINTENANCE BUNDLE. Sally Valdez, RN, BSN and Barbara Calabrese, RN. Rates reduced from 1.4 to zero with switching to the gel pad dressing andmore diligent adherence to their maintenance bundle. Timothy Royer, RN, BNS, CRNI

41. Needleless Connectors withClear Housings Timothy Royer, RN, BNS, CRNI

42. Connectors with Clear Housing Why are we using opague housings? • *INS Standard 35: INS Standard 35: Injection and Access Caps: “If the integrity of the injection or access cap is compromised or if residual blood remains within the cap, it should be replaced immediately and consideration should be given to changing the catheter and administration set.” • **Using this Standard; a needleless connector with opaque housing does not allow the nurse to see if appropriate flushing was performed and if not to continue flushing or change the valve. Just Asking *Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs. 2006;29(1S): S35. ** Hadaway L, Richardson D. Needleless connectors? A primer on terminology. Journal of Infusion Nursing. 2010, Vol. 33:1. Timothy Royer, RN, BNS, CRNI

43. Draft CDC GuidelinesExterior Housing Potential explanations for outbreaks associated with these devices include difficulty encountered in adequate disinfection of the surface of the connector due to physical characteristics of the plastic housing diaphragminterface, fluid flow properties (laminar vs. turbulent), internal surface area, potential fluid dead space, inadequate flushing of the device due to poorvisualization of the fluid flow pathway in opaque devices, and the presence of internal corrugations that could harbor organisms, particularly if the catheters are used to access blood Timothy Royer, RN, BNS, CRNI

44. Clearly Beyond the Central Line Bundle A Five-Fold Decrease of Intravascular Central Line Associated Bloodstream Infections (CLABSI) in the six months. Reduction to zero CLABSI and sustained since. (July 2009)

45. Research presented at the 2007 VHA MRSA Prevention Forum Showing the impact of clear needleless connectors in the first six months. One CLABSI in January 2007 in MICU Timothy Royer, RN, BNS, CRNI

46. Objective • Intravascular needleless connectors can be a potential source of bloodstream contamination and infection • To reduce contamination and bloodstream infections in the MICU and CCU: • Conduct staff education regarding potential sources of bloodstream infection • Implement clear valves which can be visually inspected to ensure proper flushing was performed and if residual remains, replace. Timothy Royer, RN, BNS, CRNI

47. Significant Results • Central Line Associated Bloodstream Infections decreased five-fold from 7.4/1000 line days to 1.5/1000 line days (p<0.05) • Blood Culture Contamination decreased 60% from 4.39/1000 line days to 1.77/1000 line days • Cost savings avoidance of over $241,000 • Savings of $116,000 attributed to decrease in CLABSI • Savings of $125,000 attributed to decrease in contaminated blood cultures Timothy Royer, RN, BNS, CRNI

48. Summary • After blood draws, blood residue not flushed from the valve may serve as a growth media for microbes • Most valves are opaque and blood residue cannot be visualized • Changing to a clear valve shows residue • Efficacious flushing techniques and replacing valves if visible residue remains resulted in a five-fold decrease in Intravascular Catheter Associated Bloodstream Infections Timothy Royer, RN, BNS, CRNI

49. Changes Implemented to Reach Goal of Zero • Replace standard opaque valves with clear valves that can be flushed clear • Educate staff on the importance of disinfecting valves before every access, otherwise contamination on the access port may be infused into the patient • Educate staff on the reason for practicing proper flushing techniques and for changing valves if visible residue remains, to remove growth media for microbes Timothy Royer, RN, BNS, CRNI

50. Valves may become contaminated with infusion residue or transient blood. • CLEAR VALVES provide macroscopic inspection of residue. • At our facility we reduced residue with 20-ml of flush solution. Timothy Royer, RN, BNS, CRNI