Nurse’s Knowledge

Migrating Catheters

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Washing “Bloody” Hands


The thrust of this article in the British Journal of Nursing is that safe strategies in terms of handling sharp instruments, including needles, can and must lead to the prevention of infections to patients, staff, and visitors to healthcare facilities. Without safe, well-thought-out procedures and policies with reference to the handling of needles and other sharp instruments used in hospitals and clinics, individuals in and near the healthcare activity could be inadvertently exposed to infections from blood-borne pathogens. The danger then is great, and procedures to prevent these infections are vital to hospitals and clinics.

Article Summary

Aziz, a.M., Ashton, H., Mathieson, K., Jones, S., and Mullin, B. (2009). Sharps

management in hospital: an audit of equipment, practice and awareness.

British Journal of Nursing, 18(2), 92-98.

An interesting statistic in the second paragraph of this scholarly article very clearly reflects the danger inherent in working with needles and other sharp instruments; the British National Audit Office revealed that in 2003, “needlestick injuries ranked alongside” a number of other seemingly mundane injuries as the main type of accidents incurred by staff in the National Health Service (NHS) (Aziz, et al., 2009). Those other mundane accidents include falls, trips, injuries while lifting and moving heavy items, and exposure to hazardous substances.

Indeed, in the entire British healthcare system — and likely in Australia and the United States as well — nurses were the group with the highest percentage of sharps injuries. Still, avoidable blood-borne infections are being reported on a regular basis in hospitals and clinics — in fact between 2002 and 2005 the number of reported occupational exposures to blood borne infections increased by 49% (Aziz 92). And the data shows, “about half” of those infections due to accidental exposure were reported by nurses, Aziz writes on page 92. What is needed the writers assert is local protocols that can be posted in all healthcare facilities — and published in all workplace-related brochures, newsletters, and other materials that nursing and other clinical staff have access to.

Healthcare workers must be trained to take precautions against these kinds of infections, the article continues. The average risk of transmission of blood-borne viruses after a “single percutaneous exposure” from a person already infected — in the absence of “appropriate post-exposure prophylaxis” — has been estimated by the Centers for Disease Control and Prevention (CDC, 2006) and HPA (2008) as the following (Aziz 92):

For Hepatitis B virus: 33%, or one in three exposures; for Hepatitis C virus: 1.8 — 1.9% (1 in 50 exposures); and for HIV (Human immunodeficiency virus): 0.3% (1 in 300). Those are not very good odds to take chances with for nurses and for their patients and families of patients.

With that in mind, the article offers a series of bullet points aimed at prevention of infections due to blood-borne pathogen. Some of the safety strategies are very obvious to the point of being embarrassingly rudimentary; others are perhaps not widely known or used. In either case, with such a high number of nurses reporting infections from sharps there is clearly a need for more information, perhaps more training, and certainly a heightened sense of awareness.

The article suggests avoidance of re-sheathing used needles but if it cannot be avoided, nurses should use “a specific needle re-sheathing/removing device” (those used in administering a drug or for taking blood). The company that manufactures the appropriate device is Vanishpoint from Retractable Technologies, Inc., in Texas, USA (Aziz 94). Two, when a patient is “confused or agitated” a nurse should always “get help” with the sharps; three, “never pass sharps from person to person by hand” but instead use a “clear field” or other safe receptacle to place them in; four, never leave sharps laying around and never walk around with them in hand; five, have a sharps bin near your work station so you can immediately deposit them after use; six, when disposing syringes and needles, dump them as a unit, don’t “remove the needle first” (Aziz 94).

Additionally, when transporting a blood gas syringe, the article recommends removing the needle with a proper removal device and “attach a blind hub prior to transport”; and whenever it is possible, nurses are urged to use “needleless intravenous devices” (Aziz 94). The article goes on to suggest using sharps bins that are the right size for whatever clinical activity is involved (large bins are often inappropriate because they can be kicked over). Sharps bins should be labeled correctly and have the lid on securely; bins should be located at “waist height” and “never” placed on the floor or on top of high surfaces; and it is important to transport the sharps bin properly “by the handle” or in the tray that usually accompanies smaller bins (Aziz 94).

Moreover, sharps bins should never be overfilled; they should always be correctly labeled; when disposing them they should never be placed in yellow bags but rather in clear plastic bags so those handling the disposal can clearly see what is inside the bag; and finally, it is suggested that sharps bins be stored in a “locked, segregated cupboard or clinical waste bin” that is provided for that expressed precise purpose (Aziz 94).

To sum up the article in the British Journal of Nursing, the authors assert that infection control policies in hospitals should not only include “universal precautions” to be taken around needles and sharps, but also the correct procedures for dealing with “inoculation injury and other contamination with blood and body fluids” should be spelled out thoroughly (Aziz 97). When the hospital has an intranet site available to staff, these procedures should be easy to access. And further, when there is an unfortunate accident involving infection from sharps and blood, hospital risk assessment managers need to conduct what Aziz calls a “root cause analysis”; this is recommended in the sense that further accidents of this nature must be avoided for the safety of all healthcare staff.

Critical Analysis of Infection Prevention Issue

Nurses’ Knowledge of BBPs, HBV, HCV, HIV: The Journal of Nursing Scholarship (Kagan, et al., 2009) offers the results of a survey of 180 nurses in Israel that looked into their knowledge of infections resulting from blood-borne pathogens (BBPs). The survey also queried nurses on their working understanding of the importance of handwashing, on their level of compliance with standard precautions (SPs), and with their “avoidance of therapeutic contact with BBP-infected patients” (Kagan 13).

Of the 180 nurses that participated in this survey, 159 (88.3%) were women with an average educational level of 16.40 years; the data were collected from a questionnaire that queried the nurses’ understanding of HIV, hepatitis B (HBV), and hepatitis C (HCV). The results are interesting, Kagan recounts; knowledge of HIV-related infections was “significantly higher” than knowledge of HBV and HCV. As to BBP knowledge, the survey indicated that only 54.5% (96) of the participants stated, “…all patients should be treated as BBP-carriers” (Kagan 13).

The survey also showed that there is an understandable “stigma” associated with caring for BBP infections and hence, HIV / AIDS. Due to a “lack of knowledge” many nurses (36%) in the survey indicated they simply decline to work with HIV / AIDS patients (Kagan 14).

Complications Associated with Migrating Catheters: An article in the British Journal of Community Nursing explores the issues surrounding the use of urinary catheters, pointing to the fact that the common nursing strategy when attaching catheters is “do-it-yourself” (Billington, et al., 2008). When adhesive tape and Velcro bag-straps are employed to keep catheters in place there can be problems, the authors write, due to “incorrect fixation” of those adhesive devices. And when the catheter is not applied correctly it can “migrate” into the urethra and cause “urethra trauma, infection, patient discomfort” (Billington 503). Indeed, besides the catheter’s tendency to “dislodge” when it is not properly secured, any “movement-induced trauma and inflammation can predispose the patient to infection and lead to tissue necrosis, blockage of urethra, and bladder irritability and spasms” (Billington 504).

Research conducted by the authors indicated that between 17% and 41% of catheters dislodge because of “inadequate fixation”; moreover, this often happens because the patient become irritated in the area where the catheter is in place and may tug on it, or on the connecting tube (Billington 504). And when the catheter does indeed dislodge, repeated re-insertion “carries a great risk of complications” and in turn can inflate the cost of treatment for the patient (Billington 504).

Meanwhile, the authors insist that the use of adhesive tape for securing urinary catheters is “widely regarded as being inadequate, ineffective, and not validated by clinical research” (Billington 504). Additionally, using tape to secure catheters is not using solid healthcare practices because: a) tape does not stick for any great length of time “to the lubricated external surface of the catheter”; b) taping the patient’s skin is problematic because it loosens “quickly and frequently” which can and does cause “localized skin reactions”; c) tape can increase the “risk of extraluminal contamination,” which can predispose patients to “urinary tract infections”; and d) tape, when removed, can damage skin integrity and when quickly removed cause pain — and furthermore, for the patient who is being catheterized frequently, the “build-up of adhesive on the catheter tube” and that buildup is a “focal point for bacterial colonization” (Billington 504).

As to catheter straps, if fastened too tightly they can act as tourniquets, cutting off the needed flow of blood and presenting. And at least theoretically, use of straps brings about a risk of increasing the complications such as “…deep vein thrombosis and pulmonary embolism” in those patients with “impaired lower extremity circulation” (Billington 504). Research presented in this article shows that the problem of infection due to poorly attached catheters can be reduced significantly through the use of a product called “Bard StatLock” — which, the authors insist, is an effective stabilization device because it allows movement (through a swivel clip), because it is a “sterile latex-free, tug-resistant product” (Billington 504). An article in the journal RN, incidentally, states that treating “hemodialysis catheter-related bacteremia” can cost a hospital up to $45,000.

Washing “Bloody Hands”: An article in the Australian Nursing Journal asserts, “…hand hygiene is the single most effective method of reducing the spread of infections” (Dempsey 2008). The NSW Health Department has a policy called “Directive for Infection Control” which urges healthcare professionals to “practise hand hygiene” (Dempsey 34). Even Florence Nightingale understood how critically important it was “all those years ago,” Dempsey writes; hence, it is hard to understand why “many of us seem to be good at washing our hands when obviously dirty or bloody,” but individuals in nursing seem to “struggle with the idea of washing our hands before having contact with our patients…”

That having been said, Dempsey (34) points to “gradual and constant increases” in compliance albeit she insists it has been a “long and windy road” to get healthcare professionals up to speed on the importance of washing hands.

Self-Improvement Vis-a-vis Infections: Jean DerGurahian writes in Modern Healthcare that U.S. hospitals are using technology to improve infection control strategies. Indeed, as more states mandate infection reporting, hospitals are forming collaborative relationships with other hospitals to use Web-based technologies as a means of communicating to all staff the importance of infection reporting and prevention. Twenty-Six of the 50 states now require — through law — that hospitals submit infection data to central databases in those states (DerGurahian 2009, 2). The one conundrum with reference to states requiring reporting of infections is that there is a wide variance as to which infections to require hospitals to report, how often, and how facilities are supposed to actually provide data.

Conclusion: The seriousness of the infection-related healthcare issues should get the attention of not only nurses and doctors, but of administrators as well. Whether it is catheters that are not secure, patients infected with HIV / AIDS, the need to property dispose of sharps and needles, simply washing hands, or providing incomplete information to nurses and healthcare staff — infection issues cry out for solutions.

Works Cited

Aziz, a.M., Ashton, H., Pagett, a., Mathieson, K., Jones, S., & Mullin, B. (2009).

Sharps management in hospital: an audit of equipment, practice and awareness.

British Journal of Nursing, 18(2), 92-98.

Billington, a., Crane, C., Jownally, S., Kirkwood, L., & Roodhouse, a. (2008).

Minimizing the complications associated with migrating catheters. British Journal

Of Community Nursing, 13(11), 502-504.

Dempsey, Kathy. (2009). Wash your “bloody” hands. Australian Nursing Journal,

16(6), 34.

DerGurahian, Jean. (2009). Focus on self-improvement. Modern Healthcare, 39(6),


Kagan, Ilya, Ovadia, Karin Lee, & Kaneti, Tami. (2009). Perceived Knowledge of Blood-

Borne Pathogens and Avoidance of Contact with Infected Patients. Journal of Nursing Scholarship, 41(1), 13-19.

Raymond, Martha K. (2008). Dressing Up CVC Sites. RN. Retrieved April 6, 2009,


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