Dressing change, cap change and flush

Review your facility policies and procedures.

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.

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

• Properties of CHG

  Rapid activity against gram pos & neg Bacteriocidal and bacteriostatic against skin organisms (48 hr.) Active in presence of blood & serum 50% fewer CRBSIs vs. povidone Low concentrations distrupt bacterial membrane, high concentrations cause congealing of bacterial cytoplasm

  Mask
• Latex-free exam gloves
• Drape
• Measuring tape
• Alcohol pads or swabs
• >0.5% Chlorhexidine gluconate (CHG) with 70% alcohol skin prep or povidone skin prep.
• Chlorhexidine-impregnated catheter dressing
• Skin adhesive prep and adhesive strips
• Transparent dressing
• Needleless connectors
• Various sponges
• Dressing change label

Dressing Change Scenario

• Verify dressing change order (patient, site, time)
• Wash hands it's one of the most important factors in reducing catheter related infections. (CDC, 2002).
• Gather nonsterile supplies:
  • Secure a clean and dry work area
  • Personal Protective Equipment (PPE), e.g. cap, eye protection, cover gown, non-sterile gloves as needed?
  • Alcohol pads
• Gather prefilled normal saline flush syringes and prefilled 10u heparin flush syringes (1 each for every port)
• Gather sterile supplies (examine packaging for defects)
• Sterile dressing change kit
• Antimicrobial catheter dressing if not included in kit
• Catheter stabilizing device
• Sterile needleless connector (one per port)
• ID patient
• Elicit patient concerns about the catheter
• Explain the procedure to the patient:
  • Importance of maintaining sterile field
  • Importance of avoiding respiratory contamination or use mask if patient can't face away
  • Placement of drapes
  • Expected sensations: tugging of old dressing, cold cleansing solutions, etc
• Wash hands
• Don PPE (consider a cap to control hair for you and the patient as needed)
• Don non-sterile gloves
• Position patient for site access with patient facing away from insertion site
• Assess site and arm, chest and neck for exudate, erythema, ecchymosis, palpable cord or tape burns, swelling, pain, warmth and for collateral circulation.
• Dispose of gloves, wash hands
• Open sterile dressing change kit using aseptic technique
• Retrieve and don mask
• Open chlorhexidine-impregnated sponge dressing into sterile dressing kit
• Open catheter stabilizing devices into sterile dressing kit
• Don non-sterile gloves
• Carefully loosen the old dressing by lifting the edges of the transparent dressing with an alcohol pad. Carefully lift, stretch to remove and discard the old dressing without contaminating the insertion site or dislodging the catheter. Remove the biopatch with the dressing.
• Visually inspect site for signs of: inflammation, infection, tenderness, bleeding etc.
• Use alcohol pads to remove any catheter stabilizing devices including tape.
• Dispose of non-sterile gloves, handwash and don sterile gloves using aseptic technique.
• SKIN Prep:
  • Remove any visible debris with alcohol swabs.
  • Use CHG applicator per manufacturer instruction. Completely wet the treatment area with antiseptic. Scrub with a back and forth motion, cleanse the insertion site, catheter and >2" radius from the site for 30 second
  • Do not blot, allow to dry for 30 seconds
• Apply antimicrobial dressing, align slit in the direction of the catheter.
• Apply sterile skin prep adhesive to area intended for the stabilizing device and allow 30 seconds to dry
• Secure catheter to the stabilizing device and apply to the prepared skin
• Apply the new sterile transparent dressing, placing the insertion site in the center of the dressing.
• Measure external catheter length and arm circumference 10cm above and below the antecubital fossa. Apply label to dressing that identifies the date of dressing change, type & external length of catheter and arm circumference.

Changing the needleless connectors:

• Change the needleless components at least as frequently as the administration set. There is no benefit to changing these more frequently than every 72 hours.
• Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices - CDC - 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections
  • Needleless connectors and microbore extension sets with attached needleless connectors should be changed every 96 hours or with tubing changes and PRN if cracked, damaged, or contains visible blood or drug precipitates. EXCEPTION: Infusions of TPN with Intravenous Fat Emulsion (IVFE) needleless connectors should be changed every 24 hours with the tubing change.
  • Prepare a clean and dry area to work.
  • Wash hands and don non-sterile gloves.
  • Open a sterile connector package and prime the connector with a prefilled normal saline flush syringe, removing all air. (repeat one for each port)
  • Assure all clamps are securely clamped.
  • Remove the old needleless connector.
  • Use an alcohol wipe to vigorously scrub all aspects of the hub for 15 seconds and allow to air dry.*
  • Apply the new needleless connector to the hub while maintaining the
    sterility of the fluid pathway.
  • Continue until all needleless connectors have been changed.

Catheter related bloodstream infection can be prevented. The CDC believes that approximately 25,000 fewer U.S. Central Line Associated Blood Stream Infections occurred in 2009 then 2001 as a result of a collaborative effort between government and industry to improve patient safety. 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?