Central line dressing changes

NicuGal, MSN, RN · Aug 10, 2011

When we were having very high central line infection rates we rolled out at central line bundle with extensive retraining of all staff, docs, RT's etc, anyone that had contact with our lines. We also did audits and some blind audits and it was pretty astounding to see exactly how many people did break sterile technique with dressing changes and accessing lines. We had more inservices and then we checked every single person off on a check sheet for changing dressings and accessing lines.

In 2 years we have had no umbilical line related sepsis and only 8 line sepsis, and all of those were femoral lines.

You don't want to think that people aren't doing their job right, but in reality, many aren't. It amazed me to see people taking off the dressing with their sterile gloves and then proceed to go on to cleanse the site etc with those same contaminated gloves, how many people did not swab the end caps before connections, how many people laid tubing on the bed without caps (eww). And with hospital acquired line sepsis, you are looking at zero reimbursment, so you are right to start trying to get your numbers down.

ckh23, BSN, RN · Aug 10, 2011

Sorry,
This has nothing to do with being "professional", or honest. Or even trying to hold nurses soley liable. Yes, our facility does use the central line dressing kits which contain the chlorhexadine wands, a mask, biopatch, and trasparant dressing. We practice scrubbing hub, and use alcohol swabs on the hub prior to accessing the ports. We change dressings every 3 days, and tubing every 4 days. thanks for your inputs.

Part of being professional is doing things the right way and not taking shortcuts when no one is around. Also has to do with professional integrity. You said you don't want to have to watch over the shoulders of nurses when doing the dressing changes to make sure they are done properly. To me it sounds like you are suspecting the dressing change as being the culprit. If the nurses are doing the dressing changes and that IS the source then yes the nurses would be solely responsible.

What kind of protocols are in place for when the line is initially placed? For example in our facility a nurse is at the bedside wearing a mask and hairnet and is watching for any break in sterile technique or sterile field. We have a checklist that must be filled out.

tryingtohaveitall · Aug 11, 2011

Curious, do any of you place biopatches at the insertion site? Otherwise, our CVL care is the same as you've all mentioned. We went well over a year on my unit without a CRBSI utilizing these practices.

rnmi2004 · Aug 11, 2011

Sorry,
Yes, our facility does use the central line dressing kits which contain the chlorhexadine wands, a mask, biopatch, and trasparant dressing. We practice scrubbing hub, and use alcohol swabs on the hub prior to accessing the ports. We change dressings every 3 days, and tubing every 4 days. thanks for your inputs.

What makes me cringe is reading that you only change tubing Q 4 days? I'm pretty sure our policies are evidence based practice, and don't even keep peripheral IV tubing up longer than 72 hrs. My facility has very, very low rates of CLABSI. Central lines have tubing changed Q 48 hrs, Q 24 hrs if it is running TPN or an intermittent infusion. We do not access a central line without using chlorhexadine scrubs (not alcohol) and clean gloves, even just for IVP meds. We also do a Q 7 day drsg change with biopatch. Don't forget to mask the patient and any others present in the room during the procedure.

Double-Helix, BSN, RN · Aug 11, 2011

Curious, do any of you place biopatches at the insertion site? Otherwise, our CVL care is the same as you've all mentioned. We went well over a year on my unit without a CRBSI utilizing these practices.

No,we don't. Our hospital was a particpant in a large trial. Other hospitals used the bio patch and the evidence showed that a bio patch was not more effective at preventing infection than just a bio occlusive.

IVRUS, BSN, RN · Aug 11, 2011

I am currently looking for some evidence based practice to see what other hospitals do to ensure staff are really doing the central line dressing changes STERILE. Of course we dont want to hover at the bedside and watch every nurse but we do want to bring down our BSI rates. We are currently tracking specific patients and starting with educating particular nurses that may have cared for the patient. So my question to all of you is what measures does your hospital take? Thanks!

So Chief, let me first ask you, what are your CRBSI (Catheter related Blood stream infection ) rates?

And, are you doing competencies on all your staff. Each staff member performing IV therapy should be "checked" off on IVT procedures yearly such as Central line dressing changes. Starting with insertion, are you using maximum barrier precautions and is the one placing the line wearing full sterile gown, mask, & hair piece along with the sterile gloves? How are you ensuring that sterile technique is not breeched during the insertion process?

Central Line dressing changes are "usually" performed every 7 days and prn. If the dressing is loose, soiled or unocclusive, it is a prn time.

Much evidence has been gathered which shows that many of your CRBSI's can be linked to inappropriate, or lack of hub maintenance and cleaning. Are you changing your injection caps q 7 days and prn? Are your nurses scrubbing the cap for a good 30 seconds prior to accessing the cap? DO they also scrub 15 seconds inbetween accesses? (scub 30, flush, scrub 15, hang IVAB, disconnect, scrub 15, flush etc.)