Frequently Asked Questions

In 2002, Bernath reported there were no studies which compared reused tourniquets with fresh tourniquets in relation to lowering infection rates. The author did identify four articles which used surrogate outcomes (the presence of blood or microorganisms on tourniquets), but no studies were found linking contamination with infection.

More recent studies however, suggest that tourniquets may play a role in transmission of methicillin resistant Staphylococcus aureus (MRSA). Rates of MRSA positivity have ranged from 5% to 58% when portions of tourniquets were microbiologically sampled and cultured; low rates of compliance with cleaning was also reported (35.5%). A high proportion of tourniquets were also blood stained (2.8% to 37.5%).

Two methods of contamination have been suggested - (1) contamination of the tourniquet by the Health Care Practitioner's (HCP's) hands (not directly from the patient's skin) and (2) re-inoculation of the HCP's hands from the contaminated tourniquet thus allowing transmission to patients or other surfaces.

A study from 2010 that collected and tested 100 re-usable tourniquets within a 503 bed facility found that 61% of the re-usable tourniquets were colonised with bacterial species that would not be considered normal upper-limb skin flora and a quarter of the randomly collected tourniquets yielded an MRO.

Whilst the role contaminated tourniquets may have in subsequent infection is difficult to establish, disease transmission may be theoretically possible. Consequently, the following measures are recommended:

1. Hand hygiene should be regarded as the most important method by which the spread of organisms can be reduced.
2. Where possible, patients should be supplied with their own tourniquets, either reusable or disposable. Labelling of tourniquets with patient names may help in restricting use to a single patient. Reusable tourniquets should be reprocessed according to the manufacturer's instructions, when no longer required.
3. Tourniquets not assigned to a specific patient should either be disposable (single-use only) or if reusable, cleaned with alcohol-impregnated wipes after each use.
4. Blood-stained tourniquets should be discarded immediately.
5. Ample supplies of new tourniquets should be readily available for staff use.

References:

1. Australia. Monash University. Bernath V. Tourniquets in phlebotomy. [online]. February 2006 [cited 12 March 2006]. Available from http://www.med.monash.edu.au/healthservices/cce
2. Rourke C, Bates C, Read R. Poor hospital infection control practice in venepuncture and the use of tourniquets. Journal of Hospital Infection 2001; 49: 59-61.
3. Fellowes C, Kerstein R, Clark J, Azadian B. MRSA on tourniquets and keyboards. Journal of Hospital Infection 2006; 64(1): 87-88.
4. Sacar S, Turgut H, Kaleli I, Cevahir N, Asan, Sacar M, Tekin K. Poor hospital infection control practice in hand hygiene, glove utilization, and usage of tourniquets. American Journal of Infection Control 2006; 34(9): 606-609.
5. Leitch A, McCormick, Gunn I, Gillespie T. Reducing the potential for phlebotomy tourniquets to act as a reservoir for meticillin-resistant Staphylococcus aureus. Journal of Hospital Infection 2006; 63: 428 - 431.
6. Ormerod J, Williams J, Lewis J, Dawson S. Risk of MRSA transmission from tourniquets. Journal of Hospital Infection 2006; 64(3): 300-301.
7. Pinto A, Phan T, Cheong E, Siarakas S, Gottlieb. Reusable venesection tourniquets: A potential source of hospital transmission of multi resistant organism. Medical Journal of Australia 2011; 195:276-279.

There are variations between the recommendations provided by manufacturers of Intravenous fluids in regards to storage times. It is therefore imperative that staff follow the Manufacturers guidelines for the specific intravenous fluid/s that are used within their facility. Also be aware that some facilities may use more than one brand and therefore recommendations could differ between products.

A number of references and guidelines recommend against using the cubital fossa for the insertion of peripheral IV devices for the following reasons:

1. Generally, site selection should be routinely initiated in the distal areas of the upper extremities; subsequent cannulation should be made proximal to the previously cannulated site to avoid 'using up' all available veins (one of the other risks associated with inserting a PIVC below the level of a prior venipuncture is 'leaky vein syndrome' which will cause fluids infusing through the PIVC to leak out of the skin at prior insertion sites).
2. When selecting a site for peripheral intravenous venous catheterisation (PIVC), the healthcare professional (HCP) should avoid areas of flexion.
3. The antecubital fossa and metacarpal veins should be avoided if a vesicant has to be peripherally delivered due to the difficulty in detecting infiltration at these sites of flexion.
4. Median antecubital veins should be avoided in case a peripherally inserted central catheter (PICC) is required.
5. Arm veins, particularly the cephalic, antecubital fossa and basilic veins, should not be used for PIVC in patients with developing end stage renal disease (ESRD) or patients with conditions likely to lead to ESRD (particularly if preservation of upper-extremity veins is needed for fistula or graft implantation).
6. The antecubital fossa veins are not good for prolonged IV therapy and it is best to avoid this site as the veins are short and are at a joint where the median nerve and brachial artery may be injured. 
7. Generally antecubital fossa veins should be reserved for emergency procedures if a large bore catheter and/or short-term infusion is required.

It is not acceptable to attempt to disinfect gloved or ungloved fingertips in order to re-palpate the vein prior to PIVC insertion. Firstly, despite skin disinfection, bacteria present in the deeper layers of the skin may be released by manipulation of the skin when identifying the vein or other landmarks. Secondly, glove perforations have been show to be relatively frequent (7.1% following surgical operations) and consequently bacteria from the operator's hand may also contribute to contamination of the site. Thirdly, alcohol can degrade glove integrity which will increase their permeability. What is preferable is for the operator to use sterile gloves if they need to touch the access site after application of the skin antiseptic.

Reference

Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR, 2002; 51 (no. RR-10): 1-26.

It is not routinely recommended to collect blood from a Central Line but based on what has been ascertained from the literature, if blood must be collected from an intravascular catheter (excluding peripheral intravenous and haemodialysis catheters), the first few mls must be discarded prior to blood collection.

The recommended volume of discard blood varies, with some authors recommending 10mL (e.g. Cancer Institute of New South Wales {NSW}), and others a smaller discard in accordance with the device type and length e.g. 4-5mL. The amount of discard blood should be sufficient to yield a non-contaminated sample.

Use an aseptic technique including cleaning the access port(s) with a sterile, single use 70% alcohol-impregnated swab and allowing to dry prior to accessing the system.

If the lumen is not to be used, it should be locked with 0.9% normal saline (or solution recommended by the manufacturer) using a positive pressure technique. If the catheter is locked with heparin, INR or APPT should not be collected from the catheter unless peripheral bloods cannot be taken. Coagulation studies can be taken if the catheter is locked with 0.9% normal saline. A blood collection tube holder should be used.

The literature suggests the volume of the flush or lock equal at least twice the volume of the catheter plus add-on devices (if used). The catheter should be locked using the volume of solution recommended by the manufacturer (the volume is generally printed on the hub or lumen of the catheter) With regard to ports, 20mL is recommended as the flush volume following blood withdrawal. However, with all types of catheters, manufacturer's recommendations should be followed.

There are a number of references to support the use of an antimicrobial solution that is broad spectrum and has long term microbacteriocidal action after application (e.g. chlorhexidine gluconate).

• In 2006, the Infusion Nursing Standards of Practice 2006, recommend antiseptic formulations containing a combination of alcohol (either ethyl or isopropyl) and chlorhexidine gluconate for access site preparation.
• In 2003, a number of randomized controlled trials compared the clinical effectiveness and cost-effectiveness of substituting chlorhexidine for povidone-iodine when disinfecting catheter insertion sites. The study included both central vascular and peripheral venous catheters. The authors concluded "the use of chlorhexidine for patients requiring short-term vascular catheterisation, either central or peripheral catheters, would reduce the incidence of vascular catheter-related infection. It would also decrease health-care costs."
• In 2002, Hibbard et al, undertook a clinical study comparing the skin antisepsis and safety of 2% chlorhexidine gluconate (CHG) in 70% isopropyl alcohol (IPA), with 70% isopropyl alcohol and 2% aqueous chlorhexidine.3 All products demonstrated immediate (10-minute) antimicrobial activity however, CHG + IPA, produced significantly better and more persistent antimicrobial activity. Additionally, at 24 hours, the IPA alone showed a decrease in antimicrobial activity and CHG + IPA did not.
• In 1991, Maki et al reported that the rate of infections associated with central venous and arterial catheters could be significantly reduced if 2% aqueous chlorhexidine gluconate was routinely used for skin treatment prior to catheter insertion (compared to 10% povidone-iodine solution and 70% isopropyl alcohol).1 In the study, the rate of infection for alcohol alone was 7.1 per 100 catheterisations, 9.3 infections per 100 catheterisations for povidone iodine, and 2.3 infections per 100 catheterisations for chlorhexidine. Proteinaceous solutions also have little effect on the antibacterial activity of chlorhexidine.

References

1. Maki D, Ringer M, Alvarado C. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. The Lancet 1991; 338(8763): 339-344. 
2. Chaiyakunapruk N, Veenstra D, Lipsky B, Sullivan S, Saint S. Vascular catheter site care: the clinical and economic benefits of chlorhexidine gluconate compared with povidone iodine. Clin Infect Dis 2003; 37: 764-771. 
3. Hibbard J, Mulberry G, Brady A. A Clinical Study Comparing the Skin Antisepsis and Safety of ChloraPrep, 70% Isopropyl Alcohol, and 2% Aqueous Chlorhexidine. Journal of Infusion Nursing 2002; 25(4): 244-249.
4. Infusion Nurses Standards of Practice. Journal of Infusion Nursing 2006; 29(1) (Supplement): S1-S62.

Infection in short-term catheters is most often due to microbes from the skin moving along the catheter surface where the catheter enters the skin. A number of guidelines related to intravascular device management state that proper hand washing technique, meticulous site care on insertion and with dressing changes including use of approved skin cleansing agents and aseptic technique, are considered the most important measures for preventing infections associated with short-term vascular access devices. Even though PIVC have a lower risk of infection, no medical device should ever be considered risk-free with regard to infection, especially if the device is implantable. The decision by CHRISP to recommend a sterile dressing pack including drape was based on studies which demonstrated that PIVC placed in emergency situations (where establishing access is more important that maintaining asepsis) were more likely to produce severe phlebitis, as was insertion by inexperienced personnel.

References

1. Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters. A randomized, controlled trial. Ann Intern Med 1991; 114: 845-854.
2. Widmer A. Intravenous-Related Infection. In Wenzel R, ed. Prevention and Control of Nosocomial Infection. 3rd ed. Baltimore: Williams & Wilkins, 1997: 771-805.