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Are cannulae safe to use in hospitals with MRSA
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Since JAMA (October 2007) published a paper about the incidence of invasive Community associated MRSA (CA-MRSA). Now patients, doctors and healthcare workers are looking carefully at various procedures carried out in hospitals. Chhadia, A M et al; published the result of their study CA-MRSA Hand Infections in an Urban Setting, claiming 73% of healthy adults are said to carry this organism on their hands (The Journal of Hand Surgery 2007)
The various guidelines advise healthcare professionals to use the hand to place an intra- vascular device (cannula / safety cannula). This is based on studies conducted in 1980 and 1992, claiming infection rate in catheters inserted in the hand had a lower rate of phlebitis. These studies were carried out in intensive care settings and were not based on central venous catheters (CVC). CDC has now published their guidelines on hand hygiene in health care in their website, and have updated their recommendation based on the present useful information.
In September 2007, Spanish doctors published a paper and concluded the incidence of bacteria associated staphylococcus infection of blood is more common in patients having a cannula (Intra-Vascular Device) administered in ER and said to occur within 48 hours. NHS (UK) carried out thorough investigations (Ipswich Hospital) to identify causes of MRSA in hospitals. The report claims cannulae as a first major risk factor. Crnich, CJ et al assessed the risk of bloodstream Infection in adults with different intravascular devices and published their result in Mayo Clinic Proceedings: The results show that all types of IVDs pose a risk of bloodstream infection (BSI) and can be used for benchmarking rates of infection caused by the various types of cannulae in use at the present time.
Since almost all the national effort and progress to date to reduce the risk of cannulae -related infection has focused on short-term no cuffed cannulae as used in hospitals; infection control programs must now strive to consistently apply essential control measures and preventive technologies with all types of cannulae.
The use of ported cannula has been banned in USA & some countries in Europe for some time and now their lifetime use will reduce fast. CNN highlighted the problem in a news bulletin, and this has caused consternation in the US resulting in the closing of some schools. We have identified several potential causes such as the use of sterile gloves, skin asepsis, problems with cleaning solutions, introduction techniques and failure rates and fixation of cannulae to be the important factors requiring further assessment.
Doctors and nurses are not thought about hand washing and so are unaware of what effect this can have on patients. To be effective, hands should be rubbed together vigorously with soap and warm water for at least 15 seconds. Brief rubbing or simply rinsing under running water is not enough. Contaminants are stuck in oils that adhere to the skin. Agitation by rubbing loosens the dead skin cells, and soap keeps the contaminants and germs suspended in the water so they rinse off. Soap does not kill the bacteria. In fact, germicidal soaps must remain in contact with the skin for several minutes to kill germs.
Surgical hand hygiene (or antisepsis) can be performed by using either an antimicrobial soap OR an alcohol-based hand rubs with persistent activity. When an antimicrobial soap is used, the hands and forearms should be scrubbed for the length of time recommended by the product’s manufacturer, usually 2-6 minutes. Anti-bacterial soaps may give a false sense of security that could lead to less vigorous washing. (Hand Washing Week 2007 in USA. PowerPoint presentation about aseptic techniques for cannula insertion is described in the US Centers for Disease Control (CDC) guidelines (2002).
Unfortunately, because few clinical events have been observed in individual studies, it remains unclear which antiseptic solution is best, both statistically and clinically, for reducing the risk for catheter-related blood stream infection. One study found 40% of workers do not adequately wash their hands well before performing a practical invasive procedure in patients. This coupled with 70% of health adults colonising antibiotic resistant bacteria in their hand is likely to increases the chances of introducing bacteria into blood stream resulting in serious systemic infection. Using non-sterile gloves when cannulating does not prevent introduction of infection.
Healthcare professionals who introduce cannula, catheters must use proper hand and skin cleaning procedure, reduce number of attempts, adhering to aseptic technique to avoid contamination. Skin cleaning is often incomplete, and many attendants still palpate with non sterile gloves the vein puncture site before needle insertion. Accidentally introduced micro organisms grow to pathological levels and result in bacteraemia in 48 hours
There are very convincing reports from respected institutions that make doctors feel very uncomfortable in introducing cannulae in healthy adults. Cannulae can now be classified similar to a classified drug as its use can result in serious harm to the patients. The cleaning solution is not as effective (being similar to an antibiotic) and is said to have some bacteriostatic action. This may result in the introduction the organism present on the skin, resulting in severe toxemia & shock, and possible death of the patients within 48 hours.
Infections can occur in several different ways, including: contamination of the device by skin flora on insertion, migration down the cannula tract from the skin, contamination through the hub during manipulation and seeding from another infection site. With a contamination rate often as high as 50%, stopcocks (ports / hub) - used for medication injection, I.V. infusion administration, and blood sample collection-represent a potential entry portal for pathogens. Ported cannula has been banned for use in USA and some countries in Europe. NHS in UK continues to use seventeen million of these devices every year. Various hospitals in Africa, Asia and developing nations continue to use this ported cannula.
“Safety Cannulae” offer protection to doctors and nurses from sustaining “Needlestick injury” but has no added benefit to patients.
Based on recent publication and numerous publications, the cannulae manufacturers have not taken a care to bring in changes to prevent this catastrophe. Using IV Cannula is mandatory even when a patient is riddled with CA-MRSA infection. Introducing one will obviously increase your risk of introducing the bacteria into the blood stream resulting in serious consequence. As doctors who respect medical ethics “Do No Harm” must stop and think, “Is this cannula safe?” before deciding to insert one in a patient.
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http://www.safecannula.com
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