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Keeping I.V. therapy safe with needleless systems

Rosenthal, Kelli RN,BC, ANP, APRN,BC, CRNI, MS

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Kelli Rosenthal is president and chief executive officer of Oceanside, N.Y.–based ResourceNurse.com, a division of Nurses-Station.Com, LLC.

Find out how these devices can reduce your risk of injury and exposure to bloodborne pathogens.

Safety-engineered products for intravenous (I.V.) therapy have proved effective in preventing exposure of health care workers to bloodborne pathogens. In a retrospective review, the Exposure Prevention Information Network (EPINet) at the International Health Care Worker Safety Center at the University of Virginia in Charlottesville showed that the rate of percutaneous injuries among nurses declined from 19.5 per 100 occupied beds in 1993 to 9.6 per 100 occupied beds in 2001—a decrease of nearly 51%. Because these figures only include the first few months of legally mandated safety device use, they don’t fully reflect the effect of the Needlestick Safety and Prevention Act of 2001, which mandated needleless I.V. system use in all health care settings.

Safety-engineered devices prevent accidental needle sticks in two ways:primary prevention and secondary prevention. The most direct method of preventing needle-stick injuries, primary prevention techniques eliminate the need to introduce sharps into the workplace, reducing the total number of sharps used.

Secondary prevention techniques use safer sharps (for example, retractable needles) for procedures in the workplace in which therapeutic use of percutaneous techniques is necessary. In secondary prevention, the needle, or other sharp object, is made safer through blunting, shielding, or retracting. Following widespread inception, needle-stick safety programs have usually focused on secondary prevention measures. Clinicians are encouraged to use both primary and secondary sharps injury prevention techniques; however, it’s impossible to eliminate all needles from infusion therapy procedures.

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Using fewer needles

One of the best ways to prevent accidental needle-stick injuries is to eliminate as many needles from the bedside as possible: Simply put, you can’t be stuck by a needle that isn’t there. Needleless I.V. systems are defined as systems that administer medications through an I.V. access device without using needle connections.

Needleless I.V. systems have been used in infusion therapy procedures since 1991. Because of Food and Drug Administration (FDA) recommendations, about 50% of hospitals were using needleless I.V. systems by 1995. Before the 2001 act, however, many health care organizations were slow to adopt needleless systems because of the associated costs, despite their proven benefit.

A pilot study conducted in 10 New York hospitals found that needleless I.V. systems could prevent more than 93% of I.V. access-related injuries. This study also found that those individual facilities that implemented needleless I.V. systems reported reductions in I.V.-related needle-stick injuries of about 50% to 100%, depending on type of system and staff compliance.

Of 1,929 cases of needle-stick injuries among health care workers reported to EPINet in 2001, only about 8% involved sharps used to access I.V. systems, compared with 16% of 10,639 needle-stick injuries reported to EPINet from 1993 to 1995. This reduction is consistent with other reports in the literature discussing the effect of needleless I.V. systems on injury reduction among health care workers.

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Working without sharps

How are needleless systems effective? Let’s look at the systems they’ve replaced. The needles used on the I.V. tubing in the previous systems accounted for the highest rate of hospital sharps injuries.

Three types of needleless I.V. systems are available in the United States:

* prepierced septum/blunt cannula. The longest-used needleless I.V. system, this technology involves a resealable port that attaches to the hub of the patient’s access device and promotes a closed system. A blunt cannula penetrates the septum, eliminating the need for a sharp needle. Medications are administered by connecting the blunt cannula to the secondary administration set and inserting it into the prepierced septum. Because this system has a “dead space” to accommodate the cannula, failing to properly use a positive-pressure flush technique or a clamp on the system connection can allow blood to back up into the patient’s infusion catheter, increasing the risk of interruptions in therapy and elevating the risk of infection. Standard hypodermic needles can also be mistakenly used with this system.

* Luer-activated device (LAD). The LAD controls a valve that prevents the outflow of fluid through the connector until a standard Luer connector is inserted, allowing the valve to open and fluid to be inserted or withdrawn. Three types of LADs are available:

A capped LAD requires that a cap be attached to the valve when the valve’s not in use. Capped LADs are difficult to maintain aseptically because contamination can easily occur during manipulation, and the open Luer connection is difficult to swab.

A capless LAD doesn’t require capping between uses. Use a positive-pressure technique to flush the patient’s line and to close the clamp on the catheter while disconnecting the flush syringe or these devices may allow a small amount of blood to be aspirated back into the patient’s vascular access device.

A positive fluid displacement LAD is similar to the capless LAD in administration and flushing technique, but it expels fluid (usually saline from the terminal flush) back into the catheter on disconnection. This passive displacement reduces the incidence of clotted catheters. Several of these devices have gained FDA approval to be marketed as saline-only devices and don’t require 100% nursing compliance with positive-pressure technique or catheter clamping. One note of caution: Using these devices on distal valved catheters can result in valve opening, possibly encouraging blood to pool in the catheter dead space distal to the valve and potentially promoting infection.

* pressure-activated safety valve. A slit silicone disk within the catheter hub has three positions: closed, open for infusion, and open for aspiration. Because it takes about 10 inches (25 cm) of fluid to open the valve for infusion, catheters can’t occlude when an unattended infusion runs dry. Four to five times greater pressure is required to open the valve for aspiration. Proximal placement of the valve prevents it from opening with changes in intrathoracic pressure that may occur if the patient vomits, coughs, or strains.

This valve is available as either an integral component of midline catheters, peripherally inserted central catheters, tunneled central venous catheters, and subcutaneous implanted ports or as an add-on device that can be attached to the hub of any nonvalved catheter.

The valves are approved for use as saline-only devices, eliminating the need for flushing the device with heparin after an infusion or lab sampling.

Because the 2001 law requires input from health care workers using needleless I.V. devices, you may be asked to evaluate new products before they’re adopted by your institution. When choosing a needleless I.V. system, look for the following features:

* latex-free components

* minimal technique changes

* alcohol resistance

* ability to withstand pressure (for example, from power injectors for I.V. contrast in radiology)

* high flow rates (accommodates use on dialysis devices and in trauma)

* no artifacts or distortions on magnetic resonance imaging

* lipid resistance

* minimal components

* compatible with standard I.V. tubing and pump tubing

* nondefeatable safety feature (can’t be used with a needle)

* nonhemolytic (won’t affect lab samples).

Reporting all injuries according to facility policy is vital to determine how effective needleless I.V. systems are in your facility. Injuries should then be carefully evaluated to determine how the injuries occurred and what follow-up is needed.

With proper evaluation and training, needleless I.V. systems can help reduce the rate of needle-stick injuries in your facility.

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Selected References

Exposure Prevention Information Network (EPINet):Uniform Needlestick and Sharp Object Injury Report, 58 Hospitals, 2001, http://hsc.virginia.edu/medcntr/centers/epinet/soi01.html.

Hanchett, M.: “Ensure That Primary Prevention Is Part of Your Needlestick Safety Program,”Infection Control Today. December 2002, http://www.infectioncontroltoday.com/articles/2c1feat4.html.

Jagger, J., Perry, J.: “Comparison of EPINet Data for 1993 and 2001 Shows Marked Decline in Needlestick Injury Rates,” Advances in Exposure Prevention. 6( 3):25–27, April 2003.

© 2003 Lippincott Williams & Wilkins, Inc.

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