Impact of the positive pressure valve on vascular access device occlusions and bloodstream infections

Abstract

Background/Purpose

The use of needleless positive pressure connector valves (PPVs) on venous access devices (VADs) has been shown to have possible benefits in decreasing VAD occlusion rates. Catheter-related bloodstream infection (CRBSI) rates, however, have been variable. With this potential for improving patient outcomes, decreasing costs, and facilitating nursing care and catheter management, the use of PPV devices becomes both advantageous and desirable.

Methodology

This was a randomized, prospective, parallel clinical study of 160 medical and surgical step-down unit patients requiring parenteral therapies. Patients were equally randomized to two study groups to assess the impact on occlusion and CRBSI rates, using a PPV versus a standard cap without PPV. VADs included both peripherally inserted catheters (PICCs) and midlines.

Results

Seven VAD occlusions occurred; six in the experimental group, one in the control group (p = 0.43). Also, two CRBSIs occurred in the experimental group, with none in the control group (p = 0.497). All incidents occurred in doublelumen PICCs. The lack of statistical difference between the two groups for occlusions and CRBSIs indicates that the use of PPVs had no impact in preventing such outcomes. However, it was observed that the number of double-lumen PICCs and their dwelling time in the experimental group was significantly higher (p = 0.003).

Conclusion

There was no difference in the rate of catheter occlusions or CRBSIs when using PPVs or standard caps. We consider that the study outcomes may be due to the study's small sample size, and we speculate that longer dwell time of double lumen catheters may have contributed to these outcomes. These observations deserve further investigation. However, the use of PPVs may still be advantageous from a nursing process perspective.

The use of peripherally inserted venous access devices (VADs) such as midlines and peripherally inserted central catheters (PICCs) for intravenous infusions has become common practice in the hospital, as well as in the home-care setting. The main advantages of using these types of VADs include the ease of insertion, cost reduction, and lower complication rates. However, occlusion and infectious complications are not uncommon. Historically, clinicians have used a variety of techniques to prevent VAD occlusion. These include vigorous flushing, coordinated flushing and clamping, and pulsatile flow technique. Despite these methods, it has been estimated that 25% of central VADs become occluded. This leads to interruptions and delays in therapy administration and to the need for VAD replacement, associated with increased risk of complications to the patient and increased costs (Stephens, Haire, & Kotulak, 1995; Hoch, 1997). Therefore, prevention of VAD occlusion is essential. Needleless positive pressure connector valves (PPVs) prevent the reflux of blood into the VAD lumen by activating an antegrade flow of fluid through the VAD as the flush syringe is disconnected from the device. These types of devices have been shown to significantly decrease VAD occlusion rates by 8.2%, when compared to a standard connector device (Jacobs et al., 2004). However, there have been reports that PPVs increase the risk of catheter-related bloodstream infections (CRBSIs) (Rupp et al., 2007; Maragakis et al., 2006). One theory behind the increase in CRBSI rates is the possible design flaws in the PPV cap, causing microorganisms to collect in ridges and making it difficult to adequately disinfect the top of the cap prior to its use. Since these reports were published, the technology of PPVs has improved, to promote adequate cleansing prior to use.

Potential benefits of using PPVs on VADs include decreased VAD-related complications, improved patient outcomes, and cost savings. Additionally, significant cost savings with PPV use were reportedly attributed to decreased use of thrombolytics to maintain VAD patency (Rummel, Donnelly, & Fortenbaugh, 2001). The purpose of this study was to determine if the use of one of the newer generation PPVs on VADs would prevent or reduce the incidence of VAD occlusion or increase the rate of CRBSI.