At a recent INS meeting there was a discussion on the subject of changing Sterile gloves DURING the PICC insertion process.

Specifically "after acquiring access but prior to touching/trimming the PICC before threading"

I would like to continue the discussion in this forum and ask if there is any evidenced-based information on the subject

Thank you in Advance for your thoughts

Robbin George RN Vascular Access Resource Department Alexandria Hospital Virginia

 

 

Being from an OR background I

Being from an OR background I employ the double glove method, the downside being I go through 4 sets of gloves for each procedure. Starting with a closed-gloving technique, I double glove for the prep, then remove the outer layer, then double glove for the draping just in case I contaminate during this process (we do PICC's solo), then remove this outer layer. Finally I don another pair of gloves, usually 1/2 size smaller so there is better feel and complete the insertion. I wear two gloves during insertion for two reasons: 1. In case of needle stick, there is an extra layer to act as a squeegee. 2. If I contaminate my gloves then I can just remove the outer pair.

Tami Mendonca, RN, BSN

Olympic Medical Center

Port Angeles, WA

So sorry Tim, but I have to

So sorry Tim, but I have to disagree with your comments about gloves. My clinical experience with PICC insertion began in 1981, a time when we only had PICCs made of silicone. The very first PICC was made of black silicone. Silicone has a very great negative electrical charge so it does attract all particulate matter including glove powder, towel lint, dust in the air, etc. When the engineers and sales management saw how many white particules could be seen on the black catheter, they quickly changed to making them white. So there is a problem with silicone. Polyurethane does not have the problem to the same degree as silicone, thus another reason to use polyurethane.

I have never used the forcep insertion method, hate it and have never encouraged or taught its use. I want to touch the catheter to feel how it is moving up the vein, to feel any obstructions as it is threaded in. You simply can not do this with the forceps. Forceps require a tedious time consuming method. I have placed many silicone PICCs and freely advanced them by hand with gloves on. In the early days we washed our sterile gloves with sterile water. Then we switched to powder-free gloves. Our phlebitis rates were extremely low and documented in a study we published in 1993. Now, phlebitis and thrombosis are well documented to be less when the insertion site is above the ACF. At that time, long before US, we were inserting at the ACF. So the issue of powder from gloves has not been truly accounted for in a well designed study and the insertion site provides a confounding varibable that confuses the issues.

So for me, forceps are not necessary and I would not use them, ever. And I would use powder-free gloves to touch the catheter. Are you confusing powder-less gloves with powder-free gloves? There is a difference. I do agree that silicone has a problem with atracting particulate matter but it is not limited to powder from gloves. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Gloving during PICC Insertion

Robbin,

I agree with you.  Where is the evidence?  Where are the studies?

Reading this thread, I have a number of questions that I don't know where the evidence is.  Clean hand vs. sterile hand?  Gloves labeled powder free aren't powder free?

What I can offer is our practice is without any trend of complications, so I don't see this focus indicating a need for change.  Phlebitis is non-existent.  Infection rate doesn't indicate a correlation of our practice for insertion leading to increased infection or BSIs.

Gwen Irwin

Austin, Texas 

You should virtually never

You should virtually never touch the PICC with your gloved hand during insertion.  The reason is that there is powder on the glove, even if it is labled "powder-free".  This applies particuarly to silicone catheters.  All gloves are made in powered molds, and "powder-free" are washed afterwards.  the powder is very phlebitic.  Use (atraumatic if possible) forceps.  I use ones from a suture removal kit.

I use several pairs of gloves

I use several pairs of gloves when I am solo. If we have 2 RN's, one preps the arm and the other stays fully sterile. We probably do a bit of overkill on our prep but I will try to describe how we do it so we never worry about contamination.

First gloves: table prep, catheter flush, etc (including opening a small 1.5ft x1.5ft drape flat on the table), chloraprep is cracked and ready on the field.

Second gloves: left hand "dirty", right hand "clean". Using left hand, lift the pt arm into the air. Right hand takes chloraprep from the field and preps the arm 360 from below ac to axilla. Keeping arm in the air, and using the still sterile right hand, grab the pre-opened small drape and slide it under the arm. Lay the arm flat onto the drape.

Third gloves: Final glove/gown for insertion.

 

This eliminates the problem of where sterile meets dirty. It may be overkill and is definitely what I would consider an advanced prep mehod (tricky), I like it because I don't have to worry about wigglers or being to close to contamination.

Martha

I would prefer to trim the

I would prefer to trim the catheter to length, if needed, prior to any part of the procedure based on external measurements. Then have one pair of gloves dedicated to the skin prep and have a second pair dedicated to the draping and actual insertion. My reason is that it is possible to contaminate the gloves by touching linens or clothing when you are prepping the large skin area. If you take your skin prep area to the max by going to the actual place where the arm touches the bed, sometimes called the bedline in some procedures, this is even a greater possibility. After starting the insertion procedure though, I would not think that a glove change is necessary unless there has been some type of accidental contamination observed by the inserter and/or the assistant. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861