2021 INS Standards Highlight Anti-Reflux Technology for Needleless Connectors

Guest post by Nancy Moureau, RN, PhD, CEO of PICC Excellence

In vascular access, needleless connectors (NC) are now recommended worldwide to maintain closed IV systems and promote safety by preventing needlestick injuries. Over the past 25 years, many different NCs have come onto the market, with wide variations in design and function among the various types. As a result, there is a lot of confusion among clinicians regarding the proper use and management of these small yet complex devices, which can have serious patient safety implications.

Fortunately, the Infusion Nurses Society provides some clarity on this issue by significantly expanding its guidance on NCs in the 2021 Infusion Therapy Standards of Practice. This includes clearer definitions of the various types of NC technology and emphasizes the importance of understanding how to use each type properly to minimize blood reflux.

Many clinicians are not aware of the impact blood reflux can have, or view it as a minor issue that can be easily addressed with proper flushing. However, evidence is mounting that reflux is largely avoidable and leads to many complications that seriously impact patient safety.

Studies have already demonstrated the relationship between NCs, uncontrolled blood reflux and a variety of complications, including thrombotic occlusions, catheter failure and bloodstream infections. While the updated Standards do not explicitly address the importance of keeping blood out of the catheter, it’s clear that the amount of blood reflux directly impacts continued catheter function. Clinicians can reduce complications and improve patient safety by controlling blood reflux — and the choice of NC design technology plays an important role in safety.

Here’s a look at some of the key changes in the 2021 INS Standards.

Clearly Defined Categories for needleless connector Technology

The 2016 Standards generally recognized that various types of NCs with different internal mechanisms exist, but there were no clearly defined categories or discussion of how the various designs impact fluid displacement.

The 2021 Standards outline specific categories of NC technology based on the device’s internal mechanism for fluid displacement — negative displacement, positive displacement, neutral and anti-reflux. The authors also acknowledge the importance of clinicians understanding the categories and how to use each type properly. NCs with negative or positive displacement require specific, user-dependent sequences for flushing, clamping and disconnection to minimize blood reflux. It is widely accepted that education is needed to promote compliance with clamping sequences and ensure patient safety through correct usage of these devices.

Recognition of Anti-Reflux Technology & Value of Bidirectional Fluid Management

The 2021 Standards mark the first time INS has specifically recognized anti-reflux technology as a distinct category of NCs, noting that anti-reflux devices containing a bidirectional, pressure-sensitive valve have the least amount of reflux.

The Standards also recognize that additional patient factors are constantly contributing to blood movement in and out of the catheter in the form of reflux. This includes factors such as any muscle movement, change in catheter position, coughing, or vomiting — all of which cannot be solely managed by flushing. The benefit of bidirectional flow control is that, like a backcheck valve, it can automatically prevent reflux and control these physiological factors.

This special anti-reflux design also eliminates the need for user-dependent clamping/flushing sequences, which are often forgotten due to variations in user technique. As we know from handwashing and other infection control practices, the more steps, the more variations in practice. 

Importance of Standardization

Many facilities have more than one type of connector and different instructions for clamping/flushing. INS now recommends standardizing the type of needleless connector within the organization to reduce the risk for confusion about user-dependent sequences and improve clinical outcomes. Given the wide variety of NCs available, standardizing will be essential to reduce confusion and lead to longer dwell times, fewer complications and lower costs.

For more details in the 2021 INS Standards regarding needleless connectors, read Standard 36.

Looking Ahead

Many clinicians are not aware of the impact blood reflux can have, or view it as a minor issue that can be easily addressed with proper flushing. However, evidence is mounting that reflux is largely avoidable and leads to many complications that seriously impact patient safety.

Stay tuned for the 2026 INS Standards…


Nancy Moureau, PhD, RN is an international speaker and expert in vascular access. A well published researcher, she was a reviewer for the 2021 Infusion Therapy Standards of Practice. As the owner and CEO of PICC Excellence, she is committed to education and training on all aspects of vascular access. Dr. Moureau works in conjunction with Griffith University as an adjunct associate professor and a member of the AVATAR (Alliance for Vascular Access Teaching and Research).

Leave a Reply