Vascular Access Site Preparation and Skin Antisepsis
Establishes requirements for skin antisepsis and site preparation prior to vascular access device insertion, including antiseptic selection, application technique, and neonatal-specific precautions.
Vascular Access Site Preparation and Skin Antisepsis Policy
1. Policy Statement
It is the policy of this organization that skin antisepsis shall be performed before the insertion of any vascular access device (VAD), using evidence-based antiseptic agents applied with appropriate technique, and that clinicians shall assess patient-specific factors — including allergies, skin condition, and age-related physiological characteristics — to ensure safe and effective site preparation that minimizes the risk of catheter-related infection.
2. Purpose
This policy exists to:
- Establish a standardized approach to vascular access site preparation that reduces catheter-related bloodstream infections
- Ensure appropriate antiseptic agent selection based on patient-specific factors including age, allergies, and skin integrity
- Define application technique requirements that preserve antiseptic efficacy
- Protect neonatal and other vulnerable patient populations from antiseptic-related harm
- Ensure adherence to Aseptic Non Touch Technique (ANTT) principles throughout the site preparation process
3. Scope
This policy applies to:
- All clinicians performing vascular access device insertion, including short and long peripheral intravenous catheters, midline catheters, and central venous access devices
- All clinical settings within this organization where vascular access device insertion is performed
- All patient populations, including adult, pediatric, and neonatal patients
- All vascular access device types requiring skin antisepsis prior to insertion
4. Policy Requirements
4.1 Core Standards
4.1.1 Skin antisepsis shall be performed before the insertion of any vascular access device.
4.1.2 The intended insertion site shall be visibly clean before antiseptic application. When visible soiling is present, the site shall first be cleansed with soap and water before proceeding with antiseptic preparation.
4.2 Preoperative Site Preparation
4.2.1 Hair Removal
4.2.1.1 When hair at the insertion site interferes with dressing application, removal shall be performed using single-patient-use scissors or disposable-head surgical clippers.
4.2.1.2 Shaving with a razor is contraindicated for hair removal at vascular access insertion sites. Meta-analyses of randomized controlled trials demonstrate an increased risk of surgical site infection associated with razor use; clipping is superior to shaving for infection prevention.
4.2.2 Patient Assessment Prior to Antiseptic Application
4.2.2.1 Prior to antiseptic application, clinicians shall evaluate the patient’s history for any documented allergy or sensitivity to skin antiseptics.
4.2.2.2 The assessment shall include inquiry about previous reactions to chlorhexidine, iodine-based products, and alcohol-containing solutions.
4.2.2.3 Patients with known sensitivities shall receive alternative antiseptic selection to prevent catheter-associated skin injury.
4.3 Antiseptic Selection
4.3.1 Primary Agent: Alcoholic Chlorhexidine Gluconate
4.3.1.1 The preferred antiseptic for vascular access site preparation shall be alcoholic chlorhexidine gluconate (CHG). This agent is supported by systematic reviews, meta-analyses, and national evidence-based guidelines demonstrating superior efficacy in reducing catheter-related bloodstream infections compared to alternative agents.1234
4.3.1.2 The CHG solution shall contain a minimum concentration of 2% chlorhexidine gluconate combined with alcohol. Comparative studies demonstrate that 2% CHG-alcohol solutions provide significantly better protection against catheter-related bloodstream infections and bacterial colonization at insertion sites than povidone-iodine alternatives.125
4.3.2 Alternative Antiseptic Agents
4.3.2.1 When chlorhexidine is contraindicated due to documented allergy or hypersensitivity, clinicians shall select an acceptable alternative. Acceptable alternatives include iodophors such as povidone-iodine, or 70% isopropyl alcohol. Chlorhexidine-alcohol combinations remain the gold standard when clinically appropriate.
4.3.2.2 For patients who cannot tolerate alcohol-based preparations but have no chlorhexidine sensitivity, aqueous chlorhexidine formulations shall be used as an appropriate substitute. This is particularly relevant for patients with fragile or compromised skin integrity.
4.4 Special Populations: Neonatal Considerations
4.4.1 Antiseptic selection in preterm neonates, low-birthweight infants, and all neonates within the first 14 days of life shall include careful consideration of the unique physiological characteristics of immature skin.6
4.4.2 Acceptable Agents in Neonatal Populations
4.4.2.1 Povidone-iodine, alcohol-based chlorhexidine, and aqueous chlorhexidine solutions are all used in neonatal practice. Current evidence has not established any single antiseptic as definitively superior for either safety or efficacy in this population.6 Clinical judgment shall be applied in agent selection for this population.
4.4.3 Risk-Benefit Analysis
4.4.3.1 Both aqueous and alcohol-based chlorhexidine formulations shall be used with caution in neonates. The immature skin barrier characteristic of preterm and early postnatal infants creates potential for chemical burns and systemic absorption.
4.4.3.2 Clinicians shall weigh the infection prevention benefits against the theoretical and documented dermal risks when selecting antiseptic agents for this population. While systemic absorption has been documented due to skin immaturity, clinically significant systemic effects have not been definitively established in the literature.
4.4.4 Contraindicated Agents in Neonatal Populations
4.4.4.1 Tincture of iodine is contraindicated in neonatal populations due to the potential for deleterious effects on thyroid function. Systematic review evidence documents the association between topical iodine exposure and thyroid dysfunction in preterm neonates.
4.4.5 Post-Procedure Antiseptic Removal in Neonates
4.4.5.1 Povidone-iodine shall be removed from neonatal skin following procedure completion using sterile water or sterile saline.
4.4.5.2 While evidence does not demonstrate sustained toxicity from chlorhexidine remaining on neonatal skin, aqueous CHG formulations may require removal due to their soapy consistency, which can compromise dressing adherence.
4.5 Antiseptic Application Technique
4.5.1 Single-Use Applicator Systems
4.5.1.1 Antiseptic solutions shall be applied using single-use applicator devices. These systems ensure consistent delivery of the appropriate antiseptic volume and prevent cross-contamination between patients.
4.5.2 Manufacturer Specifications
4.5.2.1 Clinicians shall follow the specific manufacturer directions for use regarding appropriate application technique and required drying times. These specifications vary between products and directly influence antiseptic efficacy.
4.5.3 Drying Requirements
4.5.3.1 The antiseptic shall be allowed to dry completely through natural air evaporation before proceeding with device insertion.
4.5.3.2 Active drying methods — including wiping, fanning, or blowing on the prepared skin surface — are contraindicated, as these techniques compromise antiseptic activity and may introduce contamination.
4.5.4 Aseptic Technique
4.5.4.1 Throughout the skin antisepsis process, clinicians shall maintain Aseptic Non Touch Technique (ANTT) principles. This standardized approach ensures that key parts and key sites remain protected from contamination during site preparation and device insertion.
5. Compliance
5.1 Key Performance Indicators
- Rate of compliance with alcoholic CHG 2% use as primary antiseptic for non-neonatal VAD insertions (target: ≥95%)
- Rate of documented pre-insertion allergy and sensitivity assessment (target: ≥95%)
- Rate of single-use applicator device use for antiseptic application (target: 100%)
- Rate of air-dry compliance prior to device insertion (target: ≥95%)
- Rate of avoidance of tincture of iodine in neonatal populations (target: 100%)
- Rate of povidone-iodine removal from neonatal skin post-procedure where indicated (target: ≥95%)
- Catheter-related bloodstream infection (CRBSI) rate, reported per 1,000 catheter-days
5.2 Enforcement
Non-compliance with this policy shall be addressed through the organization’s standard performance improvement and professional accountability processes, including documentation review, direct feedback, targeted education, and escalation to unit leadership or credentialing bodies as appropriate.
6. Exceptions
Exceptions to this policy require documented clinical justification recorded in the patient’s health record, and shall be reviewed on a case-by-case basis by the clinician’s supervisor or Vascular Access Governance Committee as appropriate. Exceptions shall not become routine practice without formal policy revision. An equivalent or greater level of infection prevention precaution shall be implemented whenever a standard requirement is modified.
7. Related Documents
- Aseptic Non Touch Technique (ANTT) Policy
- Vascular Access Device Insertion Policy
- Hand Hygiene Policy
- Standard Precautions Policy
- Latex Allergy and Sensitivity Management Policy
- Infection Prevention and Control: Central Line Bundle
- Vascular Visualization Technology Policy
- Umbilical Catheter Management in Neonates Policy
8. Revision History
| Version | Date | Author | Description |
|---|---|---|---|
| 1.0 | 2024-10-03 | Vascular Access Governance Committee | Initial policy release |
| 1.1 | 2025-12-15 | Vascular Access Governance Committee | Periodic review; neonatal post-procedure care requirements clarified |
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.2016.07.001 ↩︎ ↩︎
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 ↩︎ ↩︎
Martillo MA, Uddin F, Di Natale L, et al. CLABSI prevention in a medical-surgical ICU: updating a prevention bundle to include emerging evidence and guidelines. Am J Infect Control. 2020;48(1):34-38. doi:10.1016/j.ajic.2019.09.021 ↩︎
O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011;39(4 Suppl.):S1-S34. doi:10.1016/j.ajic.2011.01.003 ↩︎
Gorski LA. Phillips’s Manual of IV Therapeutics: Evidence-Based Practice for Infusion Therapy. 8th ed. FA Davis; 2023. ↩︎
Bagheri I, Fallah B, Dadgari A, Farahani A, Salmani N. A literature review of selection of appropriate antiseptics when inserting intravenous catheters in premature infants: the challenge in neonatal intensive care unit. J Clin Neonatal. 2020;9(3):162-167. doi:10.4103/jcn.JCN_135_19 ↩︎ ↩︎
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