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Hi, this is David Thompson, a member of the Quality and Safety Research Group.
I'm a [UNKNOWN] prepared nurse who's worked
in quality and safety for about 10 years.
I've just completed my own randomized
control trial, looking at diminishing Central Line.
Associated infections, and I'm here today to
talk to you about Central Line dressing changes.
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The terminology for lines included percutaneously placed central lines,
tunneled lines, peripherally inserted central catheters or pick lines.
A vasc, vascular access devices.
May or may not include hemodialysis catheters.
Dependent on what your site has to decided to include.
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Who completes the dressing changes would be nursing personnel
who have demonstrated competency for central line dressing changes.
Including PICC teams, if you have separate
PICC teams, and nurse practitioners, and any
medical personnel's, that have demonstrated company, competency,
such as physicians and or physicians assistants.
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We believe that the frequency, that which the dressing
is changed is based on the kind of dressing.
So the CDC recommends, that often one dressing, for
the life of the line, so after reading that
and going further, it would say once weekly if
a transparent dressing issue, such as a Surbu or Tegaderm.
You change the dressing everyday if you're
using gauze dressing while the patient is bleeding.
Once the patient's bleeding has stopped and you switch over
to transparent dressing, you can change it once a week.
At time addressing is no long occlusive.
It becomes damp or is visibly soiled it is recommended that the dressing be changed.
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Equipment that you need.
We've been using chlorhexidine gluconate at 2%
with isopropyl alcohol at 70% one swab.
A set of sterile gloves in your size.
Clean gloves for removing the dressing.
Your transparent dressing or gauze.
Mask for person applying the dressing.
A cone mask for the patient, skin prep,
take if gauze dressing is going to be used.
Additional supplies that you may need sterile cotton tipped applicators, if
you need to cleanse the insertion site of blood, a sterile
cup to hold the sterile saline that you're going to be
using to cleanse the insertion site and again, the normal saline.
Adhesive removal pads or alcohol wipes to get the dressing off, and sterile
2 by 2 gauze if you're going to be applying a gauze dressing.
In order to prepare, explain the procedure thoroughly to
the patient and any family members in the room.
Again, always wash your hands.
It's one of the most effective things that
we do to decrease infections in our patients.
Don clean gloves and remove the old dressing
using alcohol swab or adhesive remover pads as needed.
Inspect your insertion site of catheter for signs
of infection such as redness, bruising, swelling, discharge.
Culture if necessary, and assess the security of the sutures, because you need
to have the catheter held in place as you apply the antisepsis.
Remove your gloves, after the dressing is off.
Open your sterile gloves and create a
sterile field using your sterile glove package.
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Then, open your Chlorhexidine Gluconate 2% with Isopropyl Alcohol
70% swab and drop it onto your sterile field.
Open your transparent dressing and put that in your sterile field as well.
Open your skin prep and place on the outer edge of
the sterile field and then put on your sterile gloves to begin.
Cleansing the site.
Cleanse the site with the chlorhexidine gluconate
at 2% with isopropyl alcohol 70% swab.
Using friction or scrubbing motion to apply begin
directly at the insertion site and as you move
the swab outward in a circular motion to
cover all areas without retracing the area already cleansed.
Some sites have identified that the
package inserts requires a back-and-forth movement.
There have never been a study that has been large enough or with a
sample size large enough that we could say one way is better than the other.
If your hospital epidemiology or infection control nurse prefers you to
do it per the package insert, just apply it that way.
What is important is the friction motion and getting the Chlorhexidine on the
top and the back of all the skin cells that are in contact.
Allow the chlorhexidine gluconate to dry by air only.
Do not wave or allow fans to be used to dry.
It takes about 2 minutes for it to dry completely, and
please allow the 2 minutes so that the dressing will adhere appropriately.
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Now, preparing to place your dressing, you're going to designate one
hand to be unsterile, and pick up the skin prep packet.
Remove the skin prep with the sterile hand.
Apply the skin prep from the outer perimeter of
the skin where the dressing edge will touch the patient.
Do not put the skin prep over
the catheter insertion site or immediate surrounding area.
Allow to completely dry.
Once the skin prep has completely dried, using your
sterile hand, apply your
transparent dressing per manufacturer's recommendation.
And again, this means putting it down without allowing
any air bubbles you want it to go flat.
You want to even it out.
You wanna make sure that it is firmly secured.
You wanna label your dressing with the date, your
time, and your initials to identify when it was changed.
If your protocol at your hospital is also to document in
the chart, also document in the chart or on the flow sheet.
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And then finally, I'd like to talk about
some other options that you have for dressing changes.
At the time we put this together, there
are a lot of alternative things on the market.
There are bio patches, there are Chlorhexidine
impregnated catheters that are
Chlorhexidine impregnated dressing changes.
One of the most recent articles I read came out only few days ago, March 25th, in
Jama, and it talks about reducing bloodstream infections
from two per 1,000 to 0.6 per 1,000 using the bio patch.
We do recommend the bio patch if you're having
a difficult time keeping your infection control rates low.
However, in looking at the Jama study, it's very different than what we do.
When they place the line, they do not use Chlorhexidine.
When they change their dressing, they change their dressings at day
one, day four, and day seven, and they use isopropyl iodine.
So instead of using Chlorhexidine to clean, they're using the isopropyl iodine.
I've also been to some sites where they use both Chlorhexidine and a Chlorhexidine
patch, and really we've achieved, results that
are quite significant, alone without the bio-patch.
But, that is something that you should consider with your hospital
epidemiology and infection control department, if
you are having elevated bloodstream infections.
The same with impregnated patches and other
antibiotic coated catheters, those should be discussed thoroughly.
If you're using the model for eliminating such
wine blood stream infections, you should be able to
achieve a significant reduction in just following the evidence
used by the CDC as part of this collaborative.
Thank you.
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