Dressing change, cap change and flush

Strict adherence to aseptic technique is necessary to reduce catheter related blood stream infection (CRBSI). While aseptic technique is a constant, dressing change policy & procedure (P&P) may vary among institutions. Your institution's P&P is the best guide to safe patient care.

Standard precautions are usually sufficient for uncomplicated catheter dressing change procedures. Mask, eye protection, skin protection are minimum requirements.

Most institutions will provide a pre-packaged sterile dressing change kit.
Sterile kits will likely include:

• Properties of CHG

  Rapid activity against gram pos & neg 48 hr. antisepsis against skin organisms Active in presence of blood & serum 50% reduction in catheter-related bloodstream infections vs. povidone

  Mask
• Latex-free exam gloves
• Drape
• Measuring tape
• Alcohol pads or swabs
• Chlorhexidine gluconate (CHG) with 70% alcohol skin prep or povidone skin prep.
• Biopatch® - superabsorbant sponge releases CHG at the site for 7-days
• Adhesive strips
• Transparent dressing
• End cap
• Flushing supplies
• Various sponges
• Dressing change label

Procedure

• Gather kit/supplies, disinfect and air dry work area
• ID patient
• Position patient
• Explain the procedure to the patient:
  • Importance of maintaining sterile field
  • Importance of turning patient head away from insertion site to reduce respiratory contamination or mask if patient can't turn away.
  • Placement of drapes
  • Expected sensations: tugging of old dressing, cold cleansing solutions, etc.
• Hair control - a cap will provide the best protection against contamination.
• Don mask
• Handwashing is one of the most important factors in reducing catheter related infections. (CDC, 2002).
• Open sterile dressing change kit using aseptic technique
• Don gloves - aseptic technique
• P&Ps may require cleansing and air drying of entire arm prior to dressing change.
• Carefully remove the old dressing. Begin by loosening the edges of the transparent dressing. Carefully lift the distal dressing edge toward the proximal dressing edge. Some PICC lines are not sutured in or the anchors may have lost their adhesive. By pulling the dressing up the arm, the risk of outward catheter migration is reduced.
• Assess the site for signs of catheter migration (measure), inflammation, infection or bleeding.
• Change gloves - aseptic technique.
• Using an expanding spiral pattern, cleanse the catheter, end cap and skin from the insertion site outward at least 3 inches in diameter, with alcohol swabs. Remove any visible debris.
• Repeat with the CHG applicator using the same expanding spiral motion. Allow the application to dry.
  • If the patient is sensitive to CHG, povidone may be the next best antiseptic
  • Do not touch the site after it has been cleansed.
  • Antiseptic ointment is not recommended. The CDC discourages the use of polysporin type ointment because it does not inhibit fungal growth.
• Apply Biopatch® if appropriate.
• Apply the adhesive strips in a chevron style to firmly anchor the catheter. An alternative anchoring system may be used instead of the adhesive strips.
• Apply the new transparent dressing.
• Cleanse the old end cap again with alcohol and discard.
• Cleanse the catheter end with an alcohol swab.
• Apply the new end cap. Note: The injection port of a PICC line should be changed every 7 days, or when the port becomes soiled or contaminated. If it is removed it should be replaced by a sterile injection port (INS, 1999). The CDC recommends that clean injection ports be left in place for at least 72 hours. (CDC, 1999). Therefore, it may not be necessary to change the injection port with every dressing change.
• When changing a "Statlock®", moistening with alcohol swab/pad per manufacturer instructions, before removing. Do not forcefully remove.
• Secure the loose catheter end port.
• Flush the catheter per manufacturer/P&P. Be aware that frequent flushing with an anticoagulant may alter blood clotting (CDC, 1999), increasing the need for additional monitoring. If the PICC has a groshong-type valve on the end, heparin may not be required.
• Document

Catheter related bloodstream infection can be prevented. The Institute for Healthcare Improvement (IHI) has developed an evidence based set of interventions which when implemented together can significantly reduce the risk. The IHI interventions are known as the "Central Line Bundle". The "Central Line Bundle" includes:

* Hand Hygiene
* Maximal Barrier Precautions Upon Insertion
* Chlorhexidine Skin Antisepsis
* Optimal Catheter Site Selection
* Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

Visit the CDC site again, and examine the table (Appendix B) Summary of Recommended Frequency of Replacement for Catheters, Dressings, Administration Sets, and Fluids. Look for the answer to this question.

Intravenous tubing used with PICC lines should be replaced every 48 hours. True or False?