Product Evaluation & Purchasing: IV and Catheter-Related Technology

In this new series for 2017, we offer insights from experts in industry and in healthcare delivery regarding smart evaluation and purchasing of infection prevention and control-related products. In this installment, we address IV and catheter-related products.

[To access the first installment of this series on patient skin prep product evaluation and purchasing, CLICK HERE]

ICT: What are the key clinical situations that pose a challenge to proper catheter insertion/management/removal?

One major challenge for proper catheter care is the number of variables unique to each patient. These variables can lead to inconsistent catheter management practices. Patients need catheters placed in a variety of care settings – intensive care units, chemotherapy wards, outpatient therapy centers -- and by an increasingly diverse pool of clinicians. Patients also have diverse risk factors for infection. Those in the ICU tend to have multiple comorbidities. Patients receiving chemotherapy have suppressed immune systems, while patients receiving care in an outpatient facility are more susceptible to contamination when they head home. Regardless of care setting, proper catheter management and maintenance is critical. However, it’s one of many responsibilities in a highly time-stressed environment and may not get the time and attention it requires.
-- Pat Parks, MD, PhD, medical director, 3M Critical and Chronic Care Solutions Division

While there are many situations that a clinician must consider, one area of concern that is receiving an ever increasing amount of scrutiny these days is the potential for damage to skin caused by the adhesive within the transparent semi-permeable membranes (TSM) used to cover and protect the insertion site. Medical adhesive-related skin injury (MARSI) has a significant negative impact on patient safety. Removal of any layers of the stratum corneum during the process of adhesive removal can further reduce the skin's barrier function, which significantly compromises fluid balance and homeostasis and increases skin permeability; this leads to potential toxicity and irritation from topically applied substances, as well as an increased risk of infection. Newer, more skin sparing adhesives such as silicone are now available, and will not compromise the skin’s natural infection defenses like more traditional aggressive acrylic adhesives can.
-- John R. Hands, executive vice president, Covalon Technologies Ltd.

When you look at central and PICC lines there has been a lot of focus on the insertion process for a number of years. There are guidelines available from the CDC, SHEA and APIC that clearly outlines what must be included in an insertion bundle. These guidelines have really helped decrease the number of CLABSI annually. However, the guidelines and associated bundles do not provide clear guidance for access and maintenance of the lines. Greater than 71 percent of CLABSIs occur greater than five days after the insertion of a line indicating an access or maintenance issue.1 Here’s a look at some of the key issues around maintenance of the lines:
1. Lack of a standardized approach to the care and maintenance of the needleless connector or hub. Utilizing the “scrub the hub” method can be effective if a facility has high compliance with when to scrub, how long to scrub and how long to let the hub dry. If true compliance to the scrub the hub protocol is lacking, there may be inadequate disinfection of the hubs.
2. Dressing change supplies are not always included in one kit. Depending on the type of line, the clinician has to remember to pull the kit, but also additional supplies to complete the change. This sets up a situation where clinicians pull supplies that “they” like to use to change the dressing, but may not conform to their facility’s protocol. This can result in protocol drift and loss of standardization, creating an opportunity for important steps to be missed.
References:
1.  Association for Professionals in Infection Control and Epidemiology. Guide to Preventing Central Line-Associated Bloodstream Infections. Washington, DC; APIC Implementation Guides, December 2015. Available at: http:// www.apic.org/Professional-Practice/Implementation-guides#Preventing.
2. The Joint Commission. Preventing Central Line-Associated Bloodstream Infections:  A Global Perspective. Oak Brook, Ill: Joint Commission Resources, May 2012. Available at:  https://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf.
-- Barbara Connell, vice president of clinical services, Medline Industries

A key challenge for clinicians is having the time to adequately assess the patient before IV cannulation of any kind is performed. With each order of IV access, the clinician must become the advocate to ensure the right line is being used for the right patient at the right time. The clinician must truly advance his/her skills and knowledge base to become a vascular access specialist. This includes the ability to determine which type of access is correctly used, placed, and removed for each and every patient.
With a pre access assessment, this will improve patient outcomes and reduce complications while improving patient satisfaction.
-- Rita Larson, senior clinical marketing manager, vascular portfolio, Teleflex, Inc.

ICT: What impact does the design of your product category have on efficacy and why?

To foster correct use and compliance, it’s important that catheter maintenance products protect all catheter access points and are intuitive and easy to use. 3M’s I.V. site care solutions address infection risks at both major sources of catheter contamination – the catheter exit site and catheter port. To secure and protect the catheter exit site, 3M Tegaderm brand dressings feature advanced adhesives that are strong enough to minimize the risk of catheter migration and dislodgement, yet easily removable to protect the patient’s skin. 3M Tegaderm CHG dressings contain a transparent antimicrobial agent to help reduce the risk of contamination from skin flora, and can provide clinicians with visibility to monitor the exit site. To disinfect and protect catheter ports, 3M Curos brand disinfecting caps are designed to provide rapid disinfection that lasts up to 7 days and eliminates manual scrub-the-hub technique variation. Brightly colored caps also provide visual confirmation that allows hospitals to audit and improve disinfection compliance.
-- Pat Parks, MD, PhD, medical director, 3M Critical and Chronic Care Solutions Division

Several factors can influence the efficacy of an antimicrobial dressing for vascular access. Perhaps the most obvious is the type and amount of active ingredient used. IV Clear uses a unique combination of chlorhexidine and silver which has been proven to provide a synergistic effect, resulting in a lower minimum concentration of active ingredient relative to its competitive set, without sacrificing any antimicrobial efficacy. Furthermore, due to the presence of silver, IV Clear™ can work effectively against a broader spectrum of bacteria as it is commonly accepted that Pseudomonas aeruginosa is very susceptible to silver while chlorhexidine is less effective against Pseudomonas.
-- John R. Hands, executive vice president, Covalon Technologies Ltd.

According to the CDC, an estimated 30,100 central line-associated bloodstream infections (CLABSI) still occur in intensive care units and wards of U.S. acute-care facilities each year. It’s an ongoing issue that typically causes prolonged hospital stays, increased costs and risk of mortality. Yet, it is largely preventable when evidence based products and practices are followed for the insertion and maintenance of central venous catheters or CVCs. To help better meet customer needs, Medline purchased the operating assets of SwabFlush and the pre-filled saline and heparin flush syringes from Excelsior Medical. SwabFlush is the only IV catheter flush syringe that provides a disinfection cap for needleless IV connectors, built into the plunger of the syringe for the vascular access and infection control markets. The all-in-one combination of the disinfection cap and a pre-filled flush syringe promotes compliance with required protocols for both catheter flushing and disinfection of IV connectors. As a final flush, it ensures that the disinfection cap is always readily available to protect the connector between line accesses. The patent-pending ERASE BSI dressing change system utilizes educational pictograms to provide real-time instructions and evidence based products with every dressing change. This kit was designed by clinicians to help drive standardization and efficiency and reduce protocol drift.  The kit can be customized with the evidence based products that the facility is accustomed to using and can also be customized with educational pictograms to align with a facility’s protocol.
-- Barbara Connell, vice president of clinical services, Medline Industries

In an era of mandatory reporting of all CLABSIs, it’s important to recognize that not all PICCs are created equal. There are wide variations in how much protection they offer in terms of antimicrobial and antithrombotic protection. For example, PICCs using Chlorag+ard® Technology, as shown in in vivo and in vitro studies, have a chlorhexidine solution chemically bonded to the catheter surface with a controlled release that provides:
- Antimicrobial protection
- Antithrombogenic protection
- Protection against thrombotic occlusion
- Reduction in phlebitis and intimal hyperplasia.
This design provides protection on both internal and external surfaces of the catheter.
-- Rita Larson, senior clinical marketing manager, vascular portfolio, Teleflex, Inc.

ICT: What are the primary benefits of your category of IV/catheter-related products that evaluators should look for?

When looking for catheter securement dressings, evaluators should look for products that have a transparent window that allows for constant site monitoring and has the adhesive strength to properly secure the catheter. It should also deliver immediate and continuous antimicrobial protection, be effective at reducing skin flora and suppress regrowth for effective protection that lasts up to seven days to avoid frequent dressing changes. When evaluating port protection products, consider passive disinfection caps that can eliminate manual scrubbing technique variation. Look for caps that can disinfect and protect all types of ports, including needleless connectors, male luers and hemodialysis connectors. Brightly colored caps can verify that a port is clean at a glance and makes disinfection compliance monitoring easy. Select caps that can be hung from IV poles for easy access and greater compliance. To help your clinicians comply with industry guidelines and best practices, look for catheter-related products that meet current CDC and Infusion Nurses Society (INS) standards.
-- Pat Parks, MD, PhD, medical director, 3M Critical and Chronic Care Solutions Division

Any vascular access dressing evaluation needs to consider a multitude of factors. These must include the conformance of a product to the standards set by their institution, efficacy, value, transparency and patient satisfaction. The innovation within the vascular access dressing market has, until recently been somewhat stagnant. This changed when a novel, fully transparent, dual antimicrobial silicone adhesive became available. IV Clear™ exceeds modern antimicrobial standards on Gram-positive and Gram-negative bacteria and yeast commonly associated with Catheter Related Blood Stream Infections (CRBSIs) and remains fully transparent for insertion site assessment over its seven-day wear. IV Clear’s silicone adhesive technology minimizes pain during dressing changes and will not irritate skin.
-- John R. Hands, executive vice president, Covalon Technologies Ltd.

Medline is dedicated to developing products and that make it easier for caregivers to do the right thing every day. A facility should look for products that will help fulfill recommendations from the standards and guidelines. Look for evidence-based products that will help guide in achieving better patient outcomes. Also, to drive standardization and efficiency, look for products are simple and clinically intuitive to use. You have written procedures because you want your staff to follow them. Look for products are customized to your procedures and drive compliance.
-- Barbara Connell, vice president of clinical services, Medline Industries

No clinical procedure is completely risk free. Evaluators should be able to obtain objective data while implementing an antimicrobial and antithrombogenic PICC, which will show a substantial reduction in infection and thrombosis. With the reduction of infection and thrombosis, facilities will also see a shortened length of stay and reduction in overall costs per patient.
-- Rita Larson, senior clinical marketing manager, vascular portfolio, Teleflex, Inc.

ICT: How should IV/catheter-related products be trialed correctly in a facility?

The most successful product trials are conducted using current best practice guidelines. Using best practices from the CDC, INS or Institute for Healthcare Improvement (IHI) will help provide a proper testing ground. Then, start small. Keep it focused on one intervention at a time and within a single unit to determine key learnings before expanding the trial to other sites. With a steady growth in new product innovation, trial fatigue can start to creep in, so it’s important to have strong lines of communication between trial site leaders and their solutions provider. When a product trial is a collaborative effort, it can help ensure you are receiving the support you need to trial the product properly.
-- Pat Parks, MD, PhD, medical director, 3M Critical and Chronic Care Solutions Division

It’s generally best to select a couple of units to trial the products. Select units that would have the highest utilization of the products, such as the ICU. If you have a PICC team or a team that is specifically used for dressing changes, they should also be on the list. I would also look at your units that have high CLABSI rates. Make sure that you include new nurses in the trial as this will help you to determine if the product is easy to use and will help drive compliance. The first thing you need to do is to determine what your objectives are for the trial. This point is often overlooked. Everyone wants to trial a product, but few have clear sound objectives for what they want to learn. Work with the vendor to determine what data will be collected, what success looks like and what the next steps will be post-trial.
-- Barbara Connell, vice president of clinical services, Medline Industries

Every facility should adapt a method before trialing any product for data collection, and have key endpoints for which they are looking. This data should be compared with the previous data of the former product. Before trialing a product, the new product should be properly in-serviced to every inserter. If necessary, bedside placements should be assessed until insertor is fully competent. Care and Maintenance is a very important part of any trial. Each clinician responsible should be in-serviced on the proper care and maintenance of the product, with any changes to their usual protocol noted and understood. Data should be recorded on every placement, including, but not limited to, diagnosis, comorbidities, catheter days, and reason for discontinuation of line. If CLABSI was diagnosed, pertinent labs should be recorded.
-- Rita Larson, senior clinical marketing manager, vascular portfolio, Teleflex, Inc.

ICT: How should healthcare workers be educated about use of IV/catheter-related products under evaluation?

There are two main sources of education about new products under evaluation for healthcare workers. The first is a product in-service conducted by clinical experts from the solutions provider who train staff on proper use in accordance with the manufacturer’s instructions. These in-services are critical to understanding proper application to enable product efficacy. Second, it’s important to regularly retrain staff to keep the process fresh and ensure new hires are properly trained. Your solution provider should be able to provide additional training tools after the in-service including, clinical research data, “how-to” videos and posters. Some solution providers, such as 3M, also provide clinical education on the broader issues the product is intended to address, the latest clinical best practices and industry guideline changes that can help strengthen awareness for the product need and the importance of proper use.
-- Pat Parks, MD, PhD, medical director, 3M Critical and Chronic Care Solutions Division

Education should include a variety of educational methods. All healthcare workers that will be using the product should be provided in-person training on the appropriate use of the product by the vendor. If not all those workers are available for training, the vendor should provide a training for a point person at the facility who can educate the outliers. After initial training, the vendor should provide a compliance check shortly after implementation. This will ensure that participants understood the training and are following the new procedure. This allows for early detection of understanding and compliance with the new procedure. Of course, training videos or online webinars can also be helpful, but should not be the primary method for training.  Competency testing upon implementation of a new product is a must.
-- Barbara Connell, vice president of clinical services, Medline Industries

Each clinician should understand why they are trialing a new product and the endpoints in patient care they hope to achieve. This should be a group decision, and not the decision of one team member. Each clinician should be aware of the data collection mechanism, and be prepared to complete all data accordingly for each IV insertion. Adequate data should be collected pre-trial on the former product, to be able to be compared on the new product being trialed. Decisions to purchase new products should be made on end points that were decided on pre-trial.
-- Rita Larson, senior clinical marketing manager, vascular portfolio, Teleflex, Inc.