The Best Design for Intravenous Needleless Connectors - Research Proposal Example

Running Head: INTRAVENOUS NEEDLELESS CONNECTORS Choosing the best Design for Intravenous Needleless Connectors to Prevent Bloodstream Infections Insert Name Insert Grade Course Insert instructor’s Name December 17, 2010 Abstract Bloodstream infections remain one of the problem facing nursing practitioners especially with regard to needles that for a long time have been in use. At the same time nurses using these needles have not been spared as majority of them have been victims of needle-related injuries which in most cases occur when they are using the needles. Nevertheless, due to concerns of the impact of needles, numerous recommendations have been made on the suitability of needless intravenous connectors where research has confirmed that they have ability to reduce the level of bloodstream infections while at the same time provide protection to the clinician. At the same time needless connectors (NC) have not provided that 100 % safety-guarantee a situation that has been associated to the design of the NC. The current consensus is that NC that is designed appropriately and exhibit less defectives are seen to be effective inn reducing chances of bloodstream infections. Market is flooded with many NCs a situation that sometimes lead to confusion among the nurses when choosing the appropriate design. Observation made in this research is that specific steps and particular characteristics should guide the clinicians into making necessary choice decisions of acquiring new NCs for their organization. Hence what is discussed and outlined in this research paper is the process deemed to be appropriate when making design-choice of NCs. Keywords: Needless connectors, bloodstream infections, design-choice Choosing the best Design for Intravenous Needleless Connectors to Prevent Bloodstream Infections Within the medical and nursing practices, there are numerous efforts to decrease needlestick injuries and exposure to human immunodeficiency virus (HIV), hepatitis and other related blood-borne pathogens. To achieve this, many agencies are involved in processes of implementing intravenous (IV) delivery systems (Day, Paul and Williams, 2009, p.333). One of the characteristic of these systems include: built-in protection, specifically for needlestick injuries where they provide a safe means of using and disposing of an IV administration set and consists of tubing, an area of inserting the tubing into the container of IV fluid, and an adapter for connecting the tubing to the needle (Day, Paul and Williams, 2009, p.333). Many companies produce needless apparatus and IV line connectors, which permit instantaneous infusion of IV medications and other alternating medications without the use of needles. As a result of technology, many designs of IV line connectors that largely differ from each other are available in the market. For instance, most companies are moving away from use of the traditional stylet and such stylet include one that is self-sheathing stylet that generally is recessed into a rigid chamber at the hub of the catheter when its insertion is complete. Other designs usually place the stylet at the end of a flexible wire to avoid needlesticks (Day, Paul and Williams, 2009, p.333). Many of these designs have flooded the market that sometimes confuse nurses and other practitioners in choosing the best device but in such state of confusion, nurses are advised to largely be guided by wisdom to evaluate the institutional needs based on the best practice guidelines, as well as the institution’s policies and procedures (Day, Paul and Williams, 2009, p.333). Considering the above highlighted observation, the major issue confronting nurses is how to choose the best design of IV needless connectors in order to prevent bloodstream infections. Motivated by this, the research will try to explore and evaluate the availability of numerous designs of IV connectors, how effective they have been in use and which best choice can be embraced in order to ensure goals of prevention of bloodstream infections is realized. Review and critique of the research evidence a) Bloodstream infections The Center for Disease Control and Prevention (CDC) estimate that Healthcare-associated catheter-related bloodstream infections (HA-BSIs) constitute major cause of morbidity and mortality in USA today (Jarvis, 2010, p.2). These estimates have been colored by reports that over the same recent period, there has been about 18 % reduction in the incidences of HA-BSIs but this just constitutes a small fraction of what is necessary or required to be done (Jarvis, 2010, p.2). Nevertheless, key stakeholders remain optimistic that HA-BSIs incidences can be reduced significantly even if an outright elimination may not be achieved. Associated to the prevalence of HA-BSIs incidences have been identified to be the design of intravenous (IV) needless connectors-NCs (Jarvis, 2010, p.2). NCs constitute devices that are largely used to connect catheters, administration sets and even syringes to deliver IV therapy (Jarvis, 2010, p.2). Notable feature with most devices being used today is that many of them have become complex with regard to design and as a result this has resulted into challenge making it problematic for NCs to: disinfect, flush completely, and even use correctly (Jarvis, 2010, p.2). The issue of complexity is further compounded by the fact that there are numerous variety of designs found in the market and this has led to a situation where majority of clinicians are spoilt for choice on which specific or particular design to use in their hospital or healthcare center (Jarvis, 2010, p.3). Another observation about these devices is that their unique and different nature makes their routine-use to be different from each other with regard to disconnection, clamping, disinfection and flushing sequence and all these instances or happenings continue to gravitate the already heightened confusion among the clinicians and when this circumstances goes unchecked the lives of patients get endangered (Jarvis, 2010, p.3). b) Available designs of needless connectors In May 1999 the Stark-Boxer Healthcare Worker Needlestick Prevention Act was tabled in the Congress which subsequently led to some changes that culminated into introduction of a modified Needlestick Safety and Prevention Act, and being introduced in both houses, this Act received unanimous approval leading to former president Bill Clinton signing it into law in 2000 (Stoker, 2010, p.1). Some of the requirements of the Act were that OSHA should revise the Bloodborne Pathogen Standard and incorporate the need to use safer products and general reduction to exposure of clinicians to bloodborne pathogens while at the same, incorporating a new definition of a needless system into the Act (Stoker, 2010). Going ahead to provide definition, the Act defined needless system as, “a medical device that does not use a needle for the collection of bodily fluids, administration of medications, administration of fluids, and any other procedure with potential percutaneous exposures to a contaminated sharp and by use of needless system fewer needles would be used and needstick injuries could be avoided” (Stoker, 2010, p.1). With regard to this definition, needless connector has evolved to constitute the best means of preventing needlestick injuries and this has led to designs of many of products that have been used to fulfill goals of intravascular infusion. The first connector was known as Needle Access Injection Port, which was a famous catheter about 30 years ago. The port had features of small piece of plastic covered with latex rubber, which further was constricted with a small band around it (Stoker, 2010, p.1). When carrying out injections, the process was done through inserting a sharp convectional needle into the latex dam and injecting medication. The use of cap was mainly to provide for the opportunity in the patient’s venous system without having to necessary stick an additional needle into the patient (Stoker, 2010, p.1). This particular device was easy to disinfect where the clinician would simply wipe the top of the latex dam with relevant alcohol pad and since only a small needle was utilized in withdrawing from the injection port, there was greatly small negative displacement of blood in the catheter. Using the devices, observation was that the needles were covered or secured with tape and as evidence would later show, tape was inefficient method of providing very good security; and in many instances, disconnection occurred. At that time, needleless IV systems were in place although only about 50 per cent of hospitals used it as majority cited cost to be the biggest hindrance in using the needless devices (Stoker, 2010, p.1). After the Needle Access Injection Port, came the Pre-pierced Septum and Blunt Cannula, which constituted devices with re-sealable port that was attached to the hub of the patient’s access device where a blunt needle or cannula would be used repeatedly to penetrate the septum. The use of blunt needle abolished the need to use sharp needle and this would provide intermittent access to the vascular system (Stoker, 2010, p.1). Medication was largely administered by inserting the blunt cannula into the pre-pierced septum and this device removes the need to use a sharp needle. The major advantage of this device is that, beneath the split septum, there is location of an area that has ability to accommodate the introduction of the cannula. In addition, in the event clinician fails to utilize positive-pressure in the correct way or presence of clamp on the system connection, there are high chances that blood can flow back into the patient’s infusion catheter. When this happen the danger is that high occurrence of risk of clotting of the catheter becomes inevitable accelerating likelihood of infection taking place (Stoker, 2010, p.1). The third invention was that of Luer-Activated Port-Negative Displacement, which was realized after the adoption of the Needlestick Safety and Prevention Act and the connector become frequently on use. When the male luer is inserted into the connector, a valve opens and it becomes easier to infuse or aspirate fluid (Stoker, 2010, p.1). In addition, when the luer is removed the valve closes automatically. However, as this device became widely used, its major drawback was identified and it constituted the tendency of the device to be associated with inadvertent negative fluid, which normally takes place when the male luer is removed from the connector. As a result of this negative fluid displacement, blood is pulled into the catheter lumen and intraluminal thrombotic catheter blockages can occur. When this happens, it becomes easier for the creation of conclusions while at the same time, likelihood of growth of microorganisms becomes high. Moreover, such microorganisms normally flow into patient’s blood stream (Stoker, 2010, p.1). Further, this device has been found to be ineffective from the fact that it is unable to disinfect the surface of the device and the observation made is that when there is lack of flat and smooth surface for the connection of male luer connector insertion, this becomes a problem (Stoker, 2010, p.1). Luer-Activated-Positive Displacement was another that superseded Luer-Activated Port-Negative Displacement. This device operates on the premise that, after the syringe is removed from the connector, the needless connector pushes a small amount of solution out of the connector distally. When this happen, the fluid is pushed out of the distal end of the catheter leading to re-filling of the catheter with solution which in turn minimize occlusion (Stoker, 2010, p.1). The positive pulse that takes place clears the catheter tip from any form of blood. As a result occlusions are made less likely to form due to the sole reason that blood does not sit in a catheter for an extended period of time (Stoker, 2010, p.1). Recommendations for Practice Change According to Franklin, Tennessee, which is a published project on the importance of care and maintenance of central venous access devices, postulate that there exist numerous benefits associated with intraluminal protection connectors. These benefits in turn have a role in preventing catheter-related bloodstream infections-CR-BSI (RyMed Technologies Inc., 2010, p.1). The author of the article is Denise Macklin who establishes that there exist two groups of IV connectors: “needle-free and intraluminal protection” (RyMed Technologies Inc., 2010, p.1). The author moves ahead to differentiate the two categorizes based on their usefulness where he singles out intraluminal protection connectors to have some useful advantages over the simple needle-free connectors (RyMed Technologies Inc, 2010). According to the author, “connectors are the gateway to the intraluminal pathway and the design of the intraluminal protection connector helps prevent biofilm formation and fibrin adhesion, which are the preconditions for CR-BSI” (RyMed Technologies Inc, 2010, p.1). On the other hand, needle-free connectors according to the same author, “have too many moving parts and hard-to-reach surfaces are difficult to properly disinfect and also they further place a large educational and practice burden on nurses which in turn increases the opportunity for misuse” (RyMed Technologies Inc., 2010, p.1). According to the work article titled, ‘Seminars in Oncology Nursing’, numerous suggestions have been given as to how key features can be identified which constitute the best elements to look for when evaluating and making selection for IV connectors. Key characteristics to put into consideration include: “smooth septum, where it is recommended that a smooth septum surface that is about 99.9 % decontaminated when swabbed with alcohol. To do this appropriate use of technique is necessary; straight fluid pathway, this aspect has been identified to possess the ability to reduce catheter occlusions and CR-BSI in the clinical setting. Next element has to do with zero fluid displacement, whereby nurses when disconnecting the catheter and connector, most connectors require nurses to employ special clamping sequences. In turn the clamping sequence prevent blood reflux into the catheter which is a source of fibrin adhesion occlusion and infection where connectors with zero fluid displacement and therefore no blood reflux eliminate the need for clamping” (RyMed Technologies Inc, 2010, p.1). Cynthia Chernecky, co-editor with Macklin’s article and a professional nurse practitioner, expressed the view that in order to reduce or realize some level of management of bloodstream infections there is need for appropriate and correct use of catheters (RyMed Technologies Inc., 2010, p.1). Her assertion is that, “proper catheter management is essential if potentially fatal CR-BSI is to be minimized and as an effort to realize this Denise Macklin has performed a valuable service by putting more emphasize on the important role that connector selection plays in infection prevention” (RyMed Technologies Inc., 2010, p.1). The evidence that comes out from these statements is that appropriate selection of connectors is necessary. In doing so, it is recommended that connectors need to have ability to be effectively disinfected and flushed. Further the connectors should have the ability where blood reflux should be prevented in order to achieve maximum and satisfactory results (RyMed Technologies Inc, 2010). Carrying out a similar study and outlining recommendations to be adopted by practitioners in selecting the best catheter connectors from the many available in the market, William Jarvis a medical practitioners identified critical features that characterize the best connectors which to him should form some of the decision-making procedures for any practitioners interested in having the best connectors. Observing the many available connectors in the market, William Jarvis noted that not all NCs have similar design problem but some have demonstrated some desirable characteristics, which can be identified by practitioners and upon choosing them such devices, have the potential to contribute positively to infection-control to majority of patients (Jarvis, 2010). The author’s first attention is drawn to the connector’s septum surface where his observation and conclusion is that many of the current connectors have complex external septum surfaces that constitute gaps and openings and presence of these two features provide space that becomes unable for the clinician to disinfect during the general normal disinfection routine (Jarvis, 2010, p.4). Due to this, the author recommend that when selecting the right connector clinicians should go for devices that have smooth external septum surface while at the same time are designed with few gaps since this makes it possible to disinfect it properly (Jarvis, 2010, p.4). The author’s next attention is drawn to the septum seal where his analysis and investigation shows that septum seals with openings between the septum and fluid pathways may form the best grounds for development of biofilms (Jarvis, 2010, p.4). When this takes place, there is the creation of opening that becomes critical entry points for pathogens. As such, the author recommends that clinicians should prefer septum seals that are tight. Further clinicians should select NC which has NC housing in order to eradicate any form of contamination and discourage any viable environment that may support development of biofilms (Jarvis, 2010, p.4). The author sees as the best NC to be utilized especially when the health of the patient is put into consideration. The third attention has to do with fluid pathways where research indicate that most NCs constitute fluid pathway that is complex and indirect which makes it difficult to flush or remove blood and other related fluids. As a result it is recommended that clinicians need to select those NC that are direct and have straight and clear fluid pathway which in turn facilitate smooth and efficient flushing of blood and other related fluids (Jarvis, 2010). Next some connectors have dead spaces that makes it difficult to be reached through flushing and therefore it is recommended that clinicians should go for those NC that have little or no dead space at all (Jarvis, 2010, p.4). Moreover, many of NCs available have complex internal mechanisms a situation that sometimes makes the device to function improperly. As a result it is recommended that selection should be made for those NCs that are more direct and have least tortuous fluid pathway (Jarvis, 2010). Furthermore, many NCs exhibit characteristics of clamping sequence which becomes a problem when both positive and negative clamping sequences are used at the same time. Due to this it has been recommended that to eliminate the problem it is wise to select those NC that do not require clamping sequence (Jarvis, 2010, p.4). Other preferred features that clinicians should look for when selecting NC is that they should choose NC that are transparent in nature and not those that are opaque. This is in addition to NC that has luer access with less or no blood reflux. Lastly NCs that can use saline in flushing instead of heparin solutions in order to avoid heparin-risk related side effects (Jarvis, 2010, p.4). Feasibility steps to implementing the identified changes In implementing needless connector system in the organization, first there should be a strategy formulated with regard to the adoption of the devices. Next there is need for the organization to set appropriate budget for the device acquisition. What is important is for the organization to ensure the budget appropriation for the devices does not constrain the organization. Further the organization needs to undertake training of its staff and other relevant personnel with regard to the needless connector system. More so, before acquiring the devices the organization has to ensure it adhere to the provisions and regulations of the OSHA Act. Many challenges and barriers with regard to implementation of this system will emanate mostly from lack of enough resources and also inadequate training in the organization. Conclusion From the above discussion, it comes out clear that Intravenous needless connectors have significantly led to reduction of bloodstream infections while at the same time reducing chances of clinicians being injured by needles. However, the rate of reduction is still low because this system is yet to be satisfactory, as more studies shows that inappropriate selection of the devices still poses a threat to patients lives. It is from these studies that numerous recommendations suggest that clinicians should be using effective guidance to select devices that are risk-free to patients’ lives while at the same time, meeting the organizational needs and budget. All in all, proper selection of NC devices has the capability to contribute to the reduction of bloodstream infections. Therefore clinicians have the role to select the best NCs available in the market using proper guidelines. References Day, R. A., Paul, P. and Williams, B. (2009). Suddarths Textbook of Canadian Medical-Surgical Nursing. Lippincott Williams & Wilkins. Jarvis, W. R. (2010). Choosing the best design for intravenous needless connectors to prevent healthcare-associated bloodstream infections. Retrieved from http://docs.google.com/viewer?a=v&q=cache:KrOmDxBh_VcJ:www.rymedtech.com/assets/files/Published%2520Articles/INFECTION%2520CONTROL%2520TODAY%2520-%2520AUGUST%25202010%2520JARVIS.pdf+how+intravenous+needless+connectors+have+helped+to+prevent+bloodstream+infection&hl=en&gl=ke&pid=bl&srcid=ADGEESjZ1x0WNyVvwrgWwtQEPe1-mfBYL1w2td1EOW2c9MvQEc6RNtUTzqPq2ogh86oQ9OfT3yaVZi0VEZj3lBckwbon6eqFfbe97MoEhz7rHWCaHdFJhnBVPg1HUmL0KtzpBUW1RQY1&sig=AHIEtbR4oDPp5aQF0Ia0v70k3PDgimR7EQ. RyMed Technologies Inc. (2010). IV Needless Connector Design Can Help Prevent CR-BSI Says Nursing Journal. Journal of Patient Safety and Quality Healthcare. Retrieved from http://www.psqh.com/product-news/534-iv-needleless-connector-design-can-help-prevent-cr-bsi-says-nursing-journal.html. Stoker, R. (2010). Preventing Bloodstream Infections: Advances in needless connectors. Retrieved from http://docs.google.com/viewer?a=v&q=cache:NDSQZdKGtVoJ:healthvie.com/wp-content/uploads/2010/10/HV0910w26.pdf+Preventing+Bloodstream+Infections+using+Intravenous+Needleless+Connectors&hl=en&gl=ke&pid=bl&srcid=ADGEESivlCq98bRzxuJ8pW0Vjxczob2UQcWN0UcTyByRIZvS0v8Krkrgzelf50itU5RWa1SHzwjR2-1Fir-4dWd8Sxq82t44tijj4Mv0TnQTLfFVovcxzbgzBptNVj83JZBam0B7Qg79&sig=AHIEtbTWiiENxQhWZUuskFHYOgNlZXR5Eg. Read More