Needleless Connectors for Vascular Access Devices Policy

1. Policy Statement

All clinicians managing peripheral and central vascular access devices shall use needleless connectors in a manner that maintains a closed infusion system, minimizes intraluminal contamination, and reduces the risk of catheter-associated bloodstream infection (CABSI).¹² Connector selection, fluid displacement management, disinfection method, replacement intervals, and manifold configuration shall comply with evidence-based standards and manufacturer instructions for use. Disinfection of the connector access surface and sides is mandatory before every access, using either active or passive disinfection technique as specified in this policy.

2. Purpose

To define the clinical indications and contraindications for needleless connector use on vascular access devices
To establish the correct flushing and clamping sequence for each needleless connector displacement type to minimize intraluminal reflux and bloodstream infection risk
To specify mandatory disinfection requirements, including active scrubbing technique, agent selection, contact and drying times, and passive disinfection cap use
To define replacement intervals and triggers for connector change, including circumstances requiring immediate replacement
To provide requirements for manifold and stopcock configurations that minimize contamination risk
To establish product selection criteria and institutional standardization expectations
To define compliance monitoring obligations for needleless connector disinfection practices

3. Scope

All registered nurses, licensed practical nurses, advanced practice providers, and other licensed clinicians who access or manage peripheral or central vascular access devices
All peripheral intravenous catheters, midlines, peripherally inserted central catheters (PICCs), tunneled central venous catheters, implanted ports, and hemodialysis access devices
All clinical settings in which vascular access devices are accessed, including inpatient, ambulatory infusion, procedural, and home health environments
All needleless connectors, passive disinfection caps, manifolds with integrated connectors, and stopcock injection ports used in conjunction with vascular access devices

4. Policy Requirements

4.1 Indications and Contraindications

4.1.1 Required Use

4.1.1.1 Needleless connectors shall be attached directly and securely to the VAD hub, the female hub of an extension set, or designated injection sites on administration sets to facilitate intermittent infusion while maintaining a closed system.

4.1.1.2 Needleless connectors shall remain attached to the VAD hub at all times when the VAD is not in active continuous infusion use, unless a specific contraindication documented in this section applies.

4.1.2 Contraindications

4.1.2.1 Needleless connectors shall not be used when administering red blood cell transfusions. The internal architecture of needleless connectors significantly reduces flow rates and is incompatible with blood product viscosity requirements.

4.1.2.2 Needleless connectors shall not be used when clinical situations require rapid continuous crystalloid infusion at rates exceeding 1000 mL/hour, including trauma resuscitation and massive hemorrhage management protocols. At these flow rates, needleless connectors impede delivery and shall be removed.

4.2 Connector Classification and Flushing Sequences

4.2.1 Fluid Displacement Classification

4.2.1.1 Clinicians shall identify the fluid displacement classification of each needleless connector in use before establishing the flushing and clamping sequence for that device. In vitro studies document reflux volumes ranging from 0.02 to 50.37 microliters across all connector types.

4.2.2 Negative Displacement Connectors

4.2.2.1 Negative displacement connectors draw fluid backward into the catheter lumen when the syringe is disconnected.

4.2.2.2 Required sequence: flush → clamp → disconnect.

4.2.3 Positive Displacement Connectors

4.2.3.1 Positive displacement connectors push a small volume of fluid forward upon disconnection.

4.2.3.2 Required sequence: flush → disconnect → clamp.

4.2.4 Antireflux Connectors

4.2.4.1 Antireflux connectors incorporate internal valves designed to minimize retrograde flow. Clinical quality improvement data demonstrate that adoption of antireflux connectors in home infusion settings is associated with reductions in catheter occlusion rates, emergency department utilization related to access complications, and alteplase rescue therapy costs.³

4.2.4.2 No specific flushing sequence is mandated for antireflux connectors; however, clamping after flush and before disconnection is advisable.

4.2.5 Neutral/Minimal Displacement Connectors

4.2.5.1 Neutral or minimal displacement connectors are not designed to generate directional fluid movement upon disconnection.

4.2.5.2 No specific sequence is required; clamping after flush is advisable.

4.2.6 When Manufacturer Guidance Is Absent

4.2.6.1 In the absence of manufacturer guidance on flushing sequence, reflux volume data shall be used to select the appropriate sequence. Pharmacy or vascular access team consultation is recommended.

4.3 Disinfection Requirements

4.3.1 Universal Disinfection Before Every Access

4.3.1.1 Thorough disinfection of the connection surface and all sides of the needleless connector is required before every access, without exception.

4.3.1.2 Disinfection shall also be performed whenever contamination occurs or is suspected, including any instance in which a syringe tip or connector contacts a non-sterile surface.

4.3.1.3 Only sterile syringe tips or sterile male luer ends may contact the connector access surface after disinfection.

4.3.2 Active Disinfection Technique

4.3.2.1 Active disinfection shall be performed by vigorous mechanical scrubbing of the access surface and sides of the needleless connector using a flat swab pad saturated with 70% isopropyl alcohol or an alcohol-based chlorhexidine gluconate (CHG) solution.

4.3.2.2 Scrubbing motion shall be straight and linear, not rotational. Pressure applied shall be equivalent to arterial compression force.

4.3.2.3 The connector shall be scrubbed twice, using a fresh swab for each application.

4.3.2.4 Scrubbing duration shall be a minimum of 5 seconds and a maximum of 15 seconds.

4.3.2.5 Drying times after scrubbing shall be observed before accessing the connector:

70% isopropyl alcohol: minimum 5-second drying time
Alcohol-based chlorhexidine gluconate: minimum 20-second drying time
Povidone-iodine: minimum 6 minutes drying time; this agent is impractical for routine connector disinfection and shall not be used as the primary disinfectant

4.3.2.6 Evidence demonstrates that CHG-based swab pads and 70% isopropyl alcohol caps both effectively reduce CABSI. Isopropyl alcohol swab pads used alone demonstrate the least effectiveness among available active disinfection options.

4.3.3 Passive Disinfection Caps

4.3.3.1 Passive disinfection caps impregnated with a disinfectant (70% isopropyl alcohol, iodinated alcohol, or chlorhexidine) may be applied between accesses as an alternative or supplement to active disinfection.

4.3.3.2 Passive disinfection caps shall be applied and removed per manufacturer instructions for use.

4.3.3.3 Once removed, passive disinfection caps shall be discarded and shall not be reattached to the connector.

4.3.3.4 Systematic reviews demonstrate that passive disinfection caps reduce CLABSI rates and improve staff compliance with disinfection requirements.¹²⁴ Passive disinfection is an acceptable and evidence-supported method when performed correctly and consistently.

4.3.4 Antimicrobial Connectors

4.3.4.1 Antimicrobial needleless connectors with silver or chlorhexidine-silver coatings may be considered for patients at elevated infection risk.

4.3.4.2 Antimicrobial connector coatings do not replace the requirement for proper disinfection before every access. All disinfection requirements in Section 4.3 apply regardless of connector coating.

4.4 Replacement Intervals and Triggers

4.4.1 Mandatory Replacement Triggers

4.4.1.1 Needleless connectors shall be replaced when any of the following conditions occur, whichever occurs first:

The connector is removed from the VAD hub for any reason
Prior to drawing blood culture samples from a central venous access device (CVAD), to reduce the risk of contamination
Per local institutional policy or procedure specifying replacement intervals
Per manufacturer instructions for use specifying maximum use duration or replacement criteria
When product integrity is lost, including visible contamination, suspected contamination, presence of residual blood or debris within the connector, or device dysfunction

4.4.2 Continuous Infusion Systems

4.4.2.1 For patients on continuous infusion, needleless connectors shall be changed with the scheduled primary administration set change, which shall occur no more frequently than every 7 days for standard infusions not containing blood, blood products, or lipid emulsions.

4.4.3 Frequency Caution

4.4.3.1 Connector changes shall not be performed more frequently than clinically required. Evidence indicates that changing connectors every 24 hours during blood or lipid infusions in certain patient populations may paradoxically increase CLABSI risk through repeated hub manipulation.

4.5 Manifolds and Stopcocks

4.5.1 Manifold Configuration

4.5.1.1 Manifold products with bonded (factory-integrated) needleless connectors are preferred over those requiring separate connector attachment.

4.5.1.2 Unused ports on manifolds shall be closed with a needleless connector rather than a solid cap to maintain the ability to flush each port and preserve a closed system.

4.5.2 Stopcock Management

4.5.2.1 Stopcocks and three-way taps shall be replaced with needleless connectors as soon as clinically indicated.

4.5.2.2 Evidence demonstrates that the method of port closure has a greater influence on contamination risk than the internal fluid displacement characteristics of the connector. Closed systems with needleless connectors consistently outperform open stopcock configurations.

4.6 Product Selection and Institutional Standardization

4.6.1 Selection Committee

4.6.1.1 Needleless connector product selection shall involve a multidisciplinary committee including nursing, infection prevention, pharmacy, and materials management representatives.

4.6.2 Standardization

4.6.2.1 Needleless connector products shall be standardized across the institution to reduce complexity, support consistent staff training and competency, and enable meaningful surveillance of infection outcomes.

4.6.3 Design Evaluation Criteria

4.6.3.1 Products under evaluation shall be assessed on the following design features: split septum construction, minimal seal length, internal cannula architecture, low internal surface area and internal volume, minimal fluid displacement, simplified flow path, and published infection risk outcome data.

4.6.3.2 Staff educational requirements and ease of correct use shall be considered in product selection decisions.

5. Compliance

5.1 Key Performance Indicators

Clinician compliance rate with active disinfection technique (scrub duration, motion, drying time) as measured by direct observation audit
Clinician compliance rate with passive disinfection cap application and replacement per manufacturer instructions
Rate of needleless connector replacement prior to blood culture collection from CVADs
Rate of needleless connector changes performed for appropriate clinical indications versus unnecessary frequent changes
CLABSI and CABSI rates tracked by unit, stratified by connector type in use
Documented product standardization across clinical units

5.2 Enforcement

Non-compliance with disinfection requirements and replacement protocols shall be addressed through the institution’s established competency, performance management, and patient safety processes. Units with sustained CLABSI rates above institutional benchmarks shall undergo focused auditing of needleless connector practices as a priority investigation area. Product selection committee decisions to modify standardized connector types shall require review of infection surveillance data and be approved by the Vascular Access Governance Committee and Infection Prevention.

6. Exceptions

Exceptions to the universal disinfection requirement are not permitted. Clinical situations in which the use of a needleless connector is contraindicated (Section 4.1.2) are predefined and do not require individual exception approval; however, removal of a needleless connector for flow-rate reasons shall be documented in the clinical record. Exceptions to institutional connector standardization for specific patient populations or clinical programs may be approved by the Vascular Access Governance Committee upon submission of documented clinical justification.

Aseptic Non-Touch Technique (ANTT) Policy
Central Venous Access Device Management Policy
Peripheral Intravenous Catheter Management Policy
Filtration in Vascular Access Device Management Policy
Add-On Devices for Vascular Access Systems Policy
Blood and Blood Component Administration Policy
Vascular Access Device Flushing and Locking Policy
CLABSI Prevention Bundle Policy
CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections

8. Revision History

Version	Date	Author	Description
1.0	2023-06-20	Vascular Access Governance Committee	Initial policy
1.1	2025-05-12	Vascular Access Governance Committee	Added passive disinfection cap evidence summary; expanded flushing sequence guidance with reflux volume data; updated manifold and stopcock requirements; revised product selection criteria

References

Rupp ME, Majorant D. Prevention of vascular catheter-related bloodstream infections. Infect Dis Clin North Am. 2016;30(4):853-868. doi:10.1016/j.idc.2016.06.001 ↩︎ ↩︎
Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol. 2022;43(5):553-569. doi:10.1017/ice.2022.87 ↩︎ ↩︎
Buzas B, Smith J, Gilbert GE, Moureau N. Home infusion pharmacy quality improvement for central venous access devices using anti-reflux needleless connectors to reduce occlusions, emergency room visits, and alteplase costs. Am J Health Syst Pharm. 2022;79(13):1079-1085. doi:10.1093/ajhp/zxac083 ↩︎
Martillo M, Zarbiv S, Gupta R, et al. A comprehensive vascular access service can reduce catheter-associated bloodstream infections and promote the appropriate use of vascular access devices. Am J Infect Control. 2020;48(4):460-464. doi:10.1016/j.ajic.2019.09.021 ↩︎

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