On the CUSP: STOP BSI Central Line Dressing Change

Terminology for Lines Included Percutaneously placed central lines Tunneled lines Peripherally inserted central catheter Vascular Access devices * May not include hemodialysis catheters. 2

Who Completes Nursing Personnel who have demonstrated competency for central line dressing changes, including PICC teams and Nurse practitioners. Medical personnel who have demonstrated competency including physicians and physician assistants. 3

Frequency Once weekly if a transparent dressing is used Every day if a gauze dressing is used while bleeding Any time a dressing is no longer occlusive, damp or visibly soiled. 4

Equipment Needed Chlorhexidine Gluconate 2% w/ Isopropyl Alcohol 70% (1 Swab)* * do not use if patient is sensitive Tincture of iodine or 70% isopropyl alcohol may be used. *do not use chlorhexidine in patients <2 years old. Sterile Gloves (appropriate size) Clean Gloves (appropriate size) Transparent dressing or gauze Mask for person applying dressing Cone mask for patient Skin prep Tape if gauze dressing is used 5

Additional Supplies that May Be Needed Sterile cotton tipped applicator (needed to cleanse insertion site) Sterile cup to hold sterile saline Sterile normal saline Adhesive removal pads or alcohol wipes Sterile 2x2 gauze 6

Procedure: Preparation Explain procedure to patient/family. Wash your hands. Don clean gloves and remove old dressing using alcohol swab or adhesive remover pads as needed. Inspect insertion site of catheter for signs of infection. Culture if needed. Assess security of sutures. Remove your gloves. Open sterile gloves and create a sterile field using sterile glove package. Continued… 7

Procedure: Sterilization Open Chlorhexidine Gluconate 2% with Isopropyl Alcohol 70% swab and drop onto sterile field. Open transparent dressing and drop onto sterile field. Open skin prep and place on outer edge of sterile field. 10. Don sterile gloves. Continued… 8

Procedure: Cleansing the Site Clean skin with Chlorhexidine Gluconate 2% with Isopropyl Alcohol 70% swab. Using friction or scrubbing motion to apply. Begin directly at the insertion site as you move swab outward in a circular motion to cover all areas without retracing the area already cleansed. Allow Chlorhexidine Gluconate 2% with Isopropyl Alcohol 70% swab to air dry completely.* *If using povidone iodine, allow to remain on the skin for at least 2 minutes, or longer until dry. 9

Preparing to Place Dressing Designate one hand to be the unsterile hand and pick up the skin prep packet. Remove skin prep pad with sterile hand. Apply skin prep on outer perimeter of skin where dressing edge will touch patient. *Do not put skin prep over the catheter insertion site or the immediate surrounding area. Allow to completely dry. *Do not apply organic solvents (e.g., acetone or ether) to the skin before insertion of catheters or during dressing changes. 10

Placing the Dressing Using your sterile hand, apply transparent dressing per manufacturer recommendations. Label the dressing with date, time and initials to identify when changed. 19. Document the dressing change on the flow sheet per protocol if indicated. 11

Other Options Please see other infection prevention options under the infectious disease series for information on Chlorhexidine impregnated patches, antibiotic coated catheters etc. 12

References Johns Hopkins Hospital, Vascular Access Device Policy (Adult) http://safercare.s3.amazonaws.com/support_media/docs/clabsi/Appendix_H_Adult_VAD_Policy.pdf MMWR Guidelines for the Prevention of Intravascular Catheter-Related Infections http://www.cdc.gov/mmwr/PDF/rr/rr5110.pdf 13

On the CUSP: STOP BSI Central Line Maintenance 14

Learning Objectives Review the evidence and recommendations for central line maintenance 15

Source of Recommendations Centers for Disease Control Society for Healthcare Epidemiology of America Infectious Diseases Society of America 16

Overview of Recommendations Central line maintenance recommendations address the following topics: Central line insertion Central line dressing changes Replacement of IV administration sets Hang time for parenteral fluids Catheter hub cleansing Removal of unnecessary lines Education 17

Central Line Insertion Ensure use of checklist Empower nurses to stop the procedure if the steps in the checklist are not followed Leadership must create a culture that supports nurses 18

Central Line Dressing Change Dressing change responsibility includes only those who have demonstrated competency: Nursing personnel including PICC teams and nurse practitioners Medical personnel including physicians and physician assistants 19

Central Line Dressing Change Frequency: Transparent dressing Every 7 days PRN if damp, loosened, or soiled Gauze dressing Every 48 hours for routine use 20

Replacement of IV Administration Sets Lipids and blood products (enhance bacterial growth) Change every 24 hours All other IV administration sets No more frequently than every 72 hours Not more than every 96 hours 21

Hang Time for Parenteral Fluids Lipid-containing parenteral nutrition Change every 24 hours All other IV fluids including nonlipid-containing parenteral nutrition No formal recommendations JHH changes nonlipid-containing IV fluids every 24 hours 22

Catheter Hub Cleansing Clean hub before accessing with Chlorhexidine or 70% alcohol No formal recommendations regarding how long to cleanse hub 23

Remove Unnecessary Lines Assess need for continued central line access during daily multidisciplinary rounds Add question to a Daily Goals worksheet Complete every day during rounds 24

Education Educate all necessary staff: Guidelines to prevent catheter-related bloodstream infections Use of central line checklist Proper insertion and maintenance of central lines Ensure competency through yearly education and examination 25

References Marschall J, Mermel LA, Classen D, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals. Infection Control and Hospital Epidemiology. 2008; 29 (supp. 1):S22-S30. O’Grady NP, Alexander M, Dellinger P, et al. Guidelines for the prevention of intravascular catheter-related infections. Infection Control and Hospital Epidemiology. 2002; 23(12):759-769. 26