Blood Reflux: Backflow, Biofilm, andSlime—Oh My!
Wednesday, April 2 7:00 8:45 AMRosen Shingle Creek Panzacola F 1/2
Thriving Thriving Amid TheAmid The Turbulent RideTurbulent Ride
2014 NHIA Annual Conference & Exposition
Thriving Amid The Turbulent Ride
A Symposium Held in Conjunction with the 2014 NHIA Annual Conference & Exposition
Supported by an educational grant fromSmiths Medical
Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 1
03S. Blood Reflux: Backflow, Biofilm, and Slime—Oh My!Wednesday, April 2 7:00 8:45 AMRosen Shingle Creek Panzacola F 1/2Supported by an educational grant from Smiths Medical
Pharmacist, Pharmacy Technician and Nurse Continuing Education Contact Hours: 1.5
ACPE Pharmacist and Pharmacy Technician Program #:0761999914145L01P & TKnowledgeBased Learning Activity
Education Overview:For the homebased patient receiving infusion therapy, a patent vascular access device (VAD) represents a lifeline to treatment. Maintainingthat lifeline to allow uninterrupted delivery of the prescribed infusion therapy is a goal of every home infusion provider, and requires anunderstanding of the catheter complications that can arise and their potential impact on patient outcomes. This program will provide acomprehensive overview of VAD thrombotic occlusions, from the effect of vascular pressure, to the pathophysiology of thrombus formation,and the relationship between occlusions, bloodstream infection and biofilms. Walk through published clinical guidelines from groups suchas the Centers for Disease Control and Prevention (CDC), and Standards of Practice from the Infusion Nurses Society (INS), as you considerthe evidence behind best practices in the prevention of catheter occlusions.
Faculty: Connie Nadeau, MBA BSN RNCNIC, Manager, Clinical Education Services, and Karen A. Tomlin, BS, MT(ASCP), CIC, Infection Preventionist, Smiths Medical, Norwell, MA
Faculty Biographical Statement:Connie Nadeau, MBA BSN RNCNIC, has over 40 years of nursing experience covering emergency, transport, neonatal and education arenas.Connie moved into industry 12 years ago and is currently the Clinical Education Manager for Smiths Medical. She and her team of registerednurses are responsible for facilitating customer education and successful product adoption on multiple Smiths Medical product portfoliosacross the US. In her role, Connie also is involved in new product development, process improvement, marketing activities and is a continuingeducation nurse planner/presenter. Connie received her BSN and MBA from Wilmington University [DE] and maintains a certification inNeonatal Intensive Care Nursing.
Karen A. Tomlin, BS, MT(ASCP), CIC is an Infection Preventionist with Smiths Medical. Certified by the Board of Infection Control, Karen isa Medical Technologist with over 28 years of infection prevention expertise in both the hospital environment and industry. Karen has participated in biofilm studies on medical devices developed a sharp safety program that has been implemented both in the US and Europe.She has contributed to performance improvement projects for reducing infection rates for surgical site and central line blood stream infections. In addition, she facilitated the implementation of evidencebased best practice resulting in reduction in MRSA and ventilator associated pneumonia. She received her Bachelor of Science degree in Medical Technology for AldersonBroaddus College and the MyersClinic Broaddus Hospital School of Medical Technology. She worked as a Medical Technologist prior to being commissioned in the United StatesAir Force where she was the Assistant Chief of Laboratory Service, attaining the rank of Captain. She ensured the quality of over 540,000annual laboratory procedures. Karen speaks nationally on the subjects of sharp safety and blood reflux.
Pharmacist, Pharmacy Technician and Nurse Education Objectives:1. Describe how blood reflux in vascular access catheters contributes to thrombotic catheter occlusions and bloodstream infections. 2. List two quality initiatives to prevent blood reflux complications.3. Identify two strategies for preventing complications created by blood reflux in the vascular access catheter.
Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition2
Learning Assessment Questions:
1. Preventing blood reflux into a catheter can reduce occlusions.a. Trueb. False
2. Biofilms are a survival mechanism for bacteria and yeast.a. Trueb. False
3. There is a relationship between thrombosis and infection.a. Trueb. False
4. Factors that influence hemodynamics include:a. Syringe connection/disconnectionb. IV bag running dryc. Patient movement d. All of the above
5. The flushclamp sequence, flushing volume and disinfection is the same for all connectors approved by the FDA.a. Trueb. False
Answers can be found on the last page of this booklet.
Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition4
Objectives
Describe how blood reflux in vascular access catheters contributes to thrombotic catheter occlusions and bloodstream infections.
List two quality initiatives to prevent blood reflux complications.
Identify two strategies for preventing complications created by blood reflux in the vascular access catheter.
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 5
Reflux & Bloodstream Infections
heoretically, blood reflux into either the IV catheter or needleless connector increases both the risk of occlusion and
biofilm formation. Both also increase the risk of Health Care Associated Blood Stream Infections.”
Infection Control Today August 2010 Vol. 14 No 8, “Choosing the Best Design for Intravenous Needleless Connector to Prevent HA-BSI” By: William R. Jarvis, MD
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition6
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 7
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition8
Hypercoagulability
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 9
Science of Fluid Dynamics
In Physics, “Fluid Dynamics” deals with fluid flow. Fluid is a substance that flows under pressure, which includes liquids and gases. Water is a fluid, air is a fluid, the sun is a fluid, even honey is a viscous fluid.
Science of Fluid Mechanics
“Fluid Mechanics” is the study of fluids, ranging from fluids at rest, to fluids in motion, to forces applied to and exerted by other fluids.
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition10
Fluid Mechanics in the Circulatory System
Human Physiology
The circulatory system is a closed pressure system • The pathway taken by blood
within the heart is called cardiac circulation.
• The pathway taken by blood from the heart to the lungs and back is called pulmonary circulation.
• The pathway taken by blood from the heart to the rest of the body and back is called systemic circulation.
Science of Fluid Pressure
Fluid Pressure Is caused by gravity, acceleration, or forces in a closed container Pressure changes are constant during IV therapy Blood reflux occurs promptly when venous pressure is greater than external infusion pressure Fluid will equalize atmospheric pressure in an open system creating back flow
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 11
Hemodynamics: Influencing Factors
Syringe connection/ disconnection Syringe plunger rebound IV bag running dry Low infusion rates External pressure
Ventilators/other hospital equipment
Patient Movement Coughing Crying Sneezing Respiration Vomiting
Mechanical Physiological
Dynamics of Vascular Pressure
Pressure mm Hg
Example (rounded pressure values)
Pressure psi
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75mm Hg Gravity pressure of fluid 100cm (39 inches) above cannulation site
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36” height above the heart = 1.33 psi overcomes the patient’s vascular pressure with gravity infusion
Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition12
Type of Thrombotic Occlusions:
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 13
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What is Biofilm?
Bacteria Yeast Algae Fungi Dynamic ecosystem of microorganisms embedded in a matrix of extracellular polymeric substances (Slimy Matrix)
Biofilm bacteria are 1000X more resistant to antibiotics than free-floating bacteria Share and transfer resistance to other organisms
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition14
The Five Stages of Biofilm Formation
1. Initial reversible attachment of free swimming microorganisms to surface 2. Permanent chemical attachment, single layer, bugs begin making slime 3. Early vertical development 4. Multiple towers with channels between, maturing biofilm 5. Mature biofilm with seeding / dispersal of more free swimming microorganisms
Graphic by Peg Dirckx and David Davies © 2003 Center for Biofilm Engineering Montana State University.
What does this all mean?
Microbes colonize intravascular catheters and connectors and form biofilms Organisms shown to cause healthcare-associated infections (HAIs) may be present in these biofilm communities Microbial communities on these devices are highly diverse, may contain organisms from skin and gastrointestinal mircobiomes or from the environment, and will likely contain substantial numbers of organisms that cannot or have not been cultured
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 15
What does this all mean?
The presence of a device-associated biofilm does not necessarily result in a device-associated infection Biofilm organisms may be pathogens or opportunistic pathogens, and multi-drug resistant Biofilm –associated organisms do not respond to therapeutically achievable concentration and may elicit disease processes by detachment of cells or aggregates or by production of endotoxins or other pyrogenic substances
“Biofilms, Medical Devices and Anti-Biofilm Technology – Challenges and Opportunities” FDA Public Workshop (February 20, 2014) Dr. Rodney Donlan, Director, CDC Biofilms Laboratory
Relationship between Thrombosis and Infection
“Shortly after insertion, intravascular catheters are coated with a conditioning film, consisting of fibrin, plasma proteins, and cellular elements, such as platelets and red blood cells. Microbes interact with the conditioning film, resulting in colonization of the catheter. There is a close association between thrombosis of central venous catheters and infection.” CDC Guidelines for the Prevention of Intravascular Catheter-Related Infection, 2011 O’Grady NP, Alexander, M, Burns LA, et al.
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition16
Relationship Between Thrombosis and Sepsis
“The presence of CRS (catheter-related sepsis) or significant catheter colonization was more frequent in patients whose catheter-related central vein thrombosis was diagnosed.”
Chest 1998; 114;207-213 Central Vein Catheter-Related Thrombosis in Intensive Care Patients: Incidence, Risk Factors, and Relationship with Catheter-Related Sepsis. By: Jean-Francois Timset, MD, PhD
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 17
Predictors of Occlusions/Infiltration
Hand
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Any Infection
Risk Factors for PIV Catheter Failure: A multivariate analysis of data from a randomized controlled study. Wallis M, McGrail M, Webster J, Marsh N, Gowardman J, Playford G, Rickard CM. Infection Control and Hospital Epidemiology.
P<0.001
Implications of Occlusion
Patient discomfort High risk of DVT (deep vein thrombosis) Increased risk of embolism Delay in treatment Increased length of stay Nursing time Increase in medication and supply cost Increased risk of infection
Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition18
Impact of Central Line-Associated Bloodstream Infections (CLABSI)
In the United States, 15 million central vascular catheter (CVC) days occur in intensive care units (ICUs) each year
Outcomes associated with hospital-acquired CLABSI • Mortality rate of 12%-25% • Increased length of hospital stay 6-10 days • Excess health care cost of $16,550
Morbidity and Mortality Weekly Report, Vital Signs: Central Line–Associated Blood Stream Infections — United States, March 1, 2011, Vol. 60
Bloodstream Infections: By Device
No. of Prospective Studies
Pooled Mean per/1000 catheter days
Arterial catheters 6 2.9
Short-term non-medicated CVC 61 2.3
Long-term tunneled and cuffed CVC 138 1.2
Peripheral venous catheters 13 0.6
Peripherally inserted CVC (PICC) 8 0.4
Subcutaneous central venous port 13 0.2
Crnich, CJ, Maki DG, The Promise of Novel Technology for the Prevention of Intravascular Device-Related Bloodstream Infections. I Pathogenesis and Short-Term Devices. CID 2002
Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 19
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition20
CMS Never Event and Public Reporting
Central Line Associated Bloodstream Infections
2011 CMS Requirements
Association for Professionals in Infection Control and Epidemiology, Inc. 3/31/10.
Standards of Evidence-Based and Best Practice
Infusion Nurses Society – INS
Association for Vascular Access – AVA
Centers for Disease Control and Prevention - CDC
Society for Healthcare Epidemiology of America - SHEA
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 21
Guidelines for Peripheral and CVCs
Needleless Connectors Add-On/ Administration Sets
Site and Dressing Changes
CDC 2011
Split septum valve preferred over mechanical valve
No more frequently than 96-hours intervals, but at least every 7 days
Peripheral catheters: 72-96 hours
SHEA 2008 (CVCs only)
Do not routinely use positive pressure needleless connectors
No longer than 96 hours
Non-tunneled CVCs, change transparent dressings every 5-7 days
INS 2011
Needleless connectors shall be Luer-lock design
Change with site rotation: up to 96 hours dependent on infusate
When clinically indicated
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition22
Needleless Technology
Negative displacement: Upon syringe disconnection, blood refluxes into catheter tip
Action: clamp BEFORE syringe disconnection
Positive displacement: Upon syringe disconnection, small amount of fluid pushes out end of catheter tip
Action: clamp AFTER syringe disconnection
Neutral displacement: Designed to minimize blood reflux into catheter tip upon syringe disconnection
Action: clamp BEFORE syringe disconnection
Anti-reflux technology: Prevents blood reflux from occurring in IV therapy due to mechanical and physiological factors Action: NO dependency on clamping sequence, reflux protection is automatic
No ISO standard on fluid displacement
Clamping does NOT stop all blood reflux potentials
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 23
Blood Reflux and Thrombosis
How much reflux is too much?
Blood Reflux associated with needleless connector into catheters between
8 – 139 L Total Incidence of Occlusion
15 L = 2.94% 30 L = 24.71%
Impact of blood reflux on the incidence of catheter occlusions – A controlled experimental trial. Hunter M. VonBriesen T, Faintuch S. 37th National Canadian Vascular Access Association Conference, 2012
Positive Needleless Connectors
SHEA – Do not routinely use positive-pressure needleless connectors with mechanical valves
FDA Alert – Initiated post market surveillance and supports SHEA’s recommendations
CDC – Split septum valve may be preferred over some mechanical valves
Risk Benefits Education
Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition24
EX
AM
INE
YO
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CT
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Are you doing what it takes to decrease the occurrence of blood reflux?
Clinical Practice: Policy and Protocol
Policy must reflect facility-specific flush protocol:
Proper flush-clamp sequence according to connector being used Proper flush solution, technique, frequency of flush,
and volume of flush Treat partial and complete occlusion in central
catheters PROMPTLY
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Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 25
Clinical Practice: Needleless Connectors
Negative Fluid Displacement Needleless Connector
Flush Clamp Remove Syringe
Positive Fluid Displacement Needleless Connector
Flush Remove Syringe Clamp
Clinical Practice: Data
Number of PIV catheters placed Number of PIV catheter days Mean, median and average dwell time Complications:
Phlebitis Infiltration and extravasation Infection Air embolism Catheter embolism Thrombosis and occlusion
Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition26
SUM
MIN
G IT
UP
Strategies to Prevent Blood Reflux
Standards of best practice
Education
Data collection– continuous quality improvement
Select new devices based on outcome evidence
Investigate new technology to reduce:
Biofilm formation, blood reflux, catheter occlusion and accidental needle stick
SUM
ING
ITM
SUM
UP
ion atEduc
andards of beSt
Strategies to Prevent Blood
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RefluxStrategies to Prevent Blood
Strategies to Prevent Blood
al nentideBiofilm format
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: educ
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al nentidecac
k ic stdlee
Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 27
DON’T FORGET!!
• Hand hygiene is king! • Site care and maintenance including a
meticulous “scrubbing the hub” routine is essential
• Assessment for complications • Catheter site dressing regimens per best
practice
Objectives
• Describe how blood reflux in vascular access catheters contributes to thrombotic catheter occlusions and bloodstream infections.
• List two quality initiatives to prevent blood reflux complications.
• Identify two strategies for preventing complications created by blood reflux in the vascular access catheter.
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!!RGET FO
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and maintare ceSit•negieyHand hhy•
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flux blood rent
Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition28
QUESTIONS?
Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 29
References:• Bagot, CN, Arya, R. Virchow and his triad: a question of attribution British Journal of Haematology. Oct2008, Vol. 143 Issue 2, p180190.• Baskin JL, ChingHon P, Reiss U, et al. Management of Occlusion and Thrombosis Associated With LongTerm Indwelling Central Venous
Catheters. Lancet. 2009 July 11; 373 (9684): 159.• Crnich, CJ, Maki DG. The Promise of Novel Technology for the Prevention of Intravascular DeviceRelated Bloodstream Infections. I
Pathogenesis and ShortTerm Devices. CID 2002• Deficit Reduction Act of 2005, Public Law 109171Feb.8, 2006, Retrieved 7/15/2013 at www.gpo.gov/fdsys/pkg/PLAW
109publ171/pdf/PLAW109publ171.pdf• FDA Memorandum, Dear Infection Control Professionals. Available at: www.fda.gov/MedicalDevices/Safety/AlertsandNotices/
ucm220459.htm Accessed July1, 2013• Hadaway L. Technology of flushing vascular access devices. J Infus Nurs. 2006; 2913745• Infusion Nursing Standards of Practice, Journal of Infusion Nursing, Volume 34, Number 1S ISSN 15331458. Revised 2011.• Jarvis W, Choosing the Best Design for Intravenous Needleless Connector to Prevent HABSI. Infection Control Today. August 2010 Vol.
14 No 8• Macklin D, What’s Physics Got to Do With It? J Vasc Access Devices. 1999;4(2): 713.• Marschall J, Mermel LA, Strategies to Prevent Central Line – Associated Bloodstream Infections in Acute Care, Infection Control and
Hospital Epidemiology, vol. 29, Supplement 1, October 2008.• McKnight S Nurse’s Guide to Understanding and Treating Thrombotic Occlusions of Central Venous Access Devices. Medsurg Nurs.
2004; 13:37782• Morbidity and Mortality Weekly Report, Vital Signs: Central Line–Associated Blood Stream Infections — United States, March 1, 2011,
Vol. 60• National Patient Safety Goals, Joint Commission, 2013. Accessed 5/10/2013 at: www.jointcommission.org/assets/1/18/NPSG_Chapter_
Jan2013_HAP.pdf• O’Grady NP, Alexander, M, Burns LA, et a. Guidelines for the Prevention of Intravascular CatheterRelated Infection, Centers for Disease
Control and Prevention, 2011 • Poole S. Central Line Infection: Improving our Surveillance, Treatment and Prevention in the Home Setting. Infusion Mar/Apr 2009. • Potera C, Biofilm Dispersing Agent Rejuvenates Older Antibiotics. Environmental Health Perspectives 2010; 118; A288• Premier Advisor Live® Hospital valuebased purchasing program: What’s in the new CMS proposed rule? 2011, Accessed 7/1/2013 at:
www.premierinc.com/advisorlive/Presentations/vbp011911.pdf• Ryder M. Needleless Connectors…minimizing the risk of bacterial transfer. Accessed 2/28/14 at: www.ncqualitycenter.org/wp
content/uploads/2013/01/Tenn_web.pdf• Sinno M, Alam M, Echocardiographically Detected Fibrinous Sheaths Associated with Central Venous Catheters. Echocardiography.
Mar2012, Vol. 29 Issue 3, pE56E59. • Timsit JF, Misset B, CarletJ, Central Vein CatheterRelated Thrombosis in Intensive Care Patients: Incidence, Risk Factors, and Relationship
with CatheterRelated Sepsis. Chest 1998; 114;207213.• Wallis M, McGrail M, Webster J. et. al. Risk factors for PIV catheter failure: a multivariate analysis of data from a randomized controlled
trial. Infection Control & Hospital Epidemiology. Under review. • Hunter M. VonBriesen T, Faintuch S. Impact of blood reflux on the incidence of catheter occlusions – A controlled experimental trial.
37th National Canadian Vascular Access Association Conference, 2012
Blood Reflux: Backflow, Biofilm, and Slime—Oh My!
2014 NHIA Annual Conference & Exposition 31
NOTES:
Answers:1. a. True2. a. True3. a. True4. d. All of the above5. b. False
32 2014 NHIA Annual Conference & Exposition
Blood Reflux: Backflow, Biofilm, and Slime—Oh My!