R E S E A R C H
Impact of the Positive Pressure Valve on
Vascular Access Device Occlusions and
Bloodstream Infections
Nabil Khalidi, PharmD, FASHP, Debra S. Kovacevich, RN, MPH, Lorelei F. Papke-OʼDonnell, CRNI, MSN, CEd,
and Imad Btaiche, PharmD, BCNSP
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 infec-
tion (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 double-
lumen 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 studyʼs 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.
T
he use of peripherally inserted venous access devices nector valves (PPVs) prevent the reflux of blood into the VAD
(VADs) such as midlines and peripherally inserted lumen by activating an antegrade flow of fluid through the VAD
central catheters (PICCs) for intravenous infusions as the flush syringe is disconnected from the device. These types
has become common practice in the hospital, as well as in the of devices have been shown to significantly decrease VAD oc-
home-care setting. The main advantages of using these types of clusion rates by 8.2%, when compared to a standard connector
VADs include the ease of insertion, cost reduction, and lower device (Jacobs et al., 2004). However, there have been reports
complication rates. However, occlusion and infectious compli- that PPVs increase the risk of catheter-related bloodstream in-
cations are not uncommon. Historically, clinicians have used a fections (CRBSIs) (Rupp et al., 2007; Maragakis et al., 2006).
variety of techniques to prevent VAD occlusion. These include One theory behind the increase in CRBSI rates is the possible
vigorous flushing, coordinated flushing and clamping, and pul- design flaws in the PPV cap, causing microorganisms to collect
satile flow technique. Despite these methods, it has been esti- in ridges and making it difficult to adequately disinfect the top
mated that 25% of central VADs become occluded. This leads of the cap prior to its use. Since these reports were published,
to interruptions and delays in therapy administration and to the technology of PPVs has improved, to promote adequate
the need for VAD replacement, associated with increased risk cleansing prior to use.
of complications to the patient and increased costs (Stephens, Potential benefits of using PPVs on VADs include decreased
Haire, & Kotulak, 1995; Hoch, 1997). Therefore, prevention of VAD-related complications, improved patient outcomes, and cost
VAD occlusion is essential. Needleless positive pressure con- savings. Additionally, significant cost savings with PPV use were
reportedly attributed to decreased use of thrombolytics to main-
tain VAD patency (Rummel, Donnelly, & Fortenbaugh, 2001).
Correspondence concerning this article should be addressed to The purpose of this study was to determine if the use of one of
nabilk@umich.edu the newer generation PPVs on VADs would prevent or reduce the
DOI: 10.2309/java.14-2-6 incidence of VAD occlusion or increase the rate of CRBSI.
84 | JAVA | Vol 14 No 2 | 2009
Methods Table 1: Demographics and VAD characteristics
Study Design for experimental and control patients
This was a randomized, prospective, parallel clinical study
that assessed the impact of using a PPV on occlusion and E C p
CRBSI rates of VADs. One hundred and sixty medical and sur- (N = 80) (N = 80)
gical adult patients on step-down units in a tertiary care hos-
Gender 0.873
pital, who were receiving parenteral therapy through a PICC
or midline VAD, were enrolled in the study. Patients were ran- Female