On the CUSP: STOP BSI Central Line Dressing Change

1. On the CUSP: STOP BSI Central Line Dressing Change

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

3. 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

4. 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

5. Transparent dressing or gauze Mask for person applying dressing Cone mask for patient Skin prep Tape if gauze dressing is used 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) 5

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. On the CUSP: STOP BSI Central Line Maintenance 14

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

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. 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

25. 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

26. 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