Change "Loose" dressings

[TexMurse]

A friend and I were discussing when a PICC dressing has to be changed. She said when it starts to roll it has to be changed. I feel a little rolling is ok, as a dressing change poses a larger risk for CLABSI. What are the thoughts out there? What does the CDC mean by "loose"?

I have found literature to support frequent dressing changes have negative outcomes, but can't find anything on the rolling edges and how they have led to CLABSIs.

[LovingLife123]

As long as the inner clear window is still completely adhered to the skin, you don’t have to change it. We change every 7 days or when the seal around the “window” is broken.

[NRSKarenRN, BSN, RN]

2016 INS- InfusionTherapy Standards of Practice:

Vascular Access Device (VAD) Assessment, Care, and Dressing Changes S81

Quote

H. Perform dressing changes on CVADs and midline catheters at a frequency based on the type of dressing.

1. Change transparent semipermeable membrane (TSM) dressings at least every 5 to 7 days and gauze dressings at least every 2 days; research has not supported the superiority of a TSM dressing versus a gauze dressing; note that a gauze dress- ing underneath a TSM dressing is considered a gauze dressing and changed at least every 2 days. 3-5,16(II)

2. Select a gauze dressing if there is drainage from the catheter exit site. If gauze is used to support the wings of a noncoring needle in an implanted port and does not obscure the insertion site, it is not considered a gauze dressing. 2-5 (V)

3. Secure dressings to reduce the risk of loosening/ dislodgment, as more frequent dressing changes due to dislodgment are associated with increased risk for infection; more than 2 dressing changes for disruption were associated with a greaterthan 3-fold increase in risk of infection. 17 (III)

4. Change the dressing immediately to closely assess, cleanse, and disinfect the site in the event of drainage, site tenderness, other signs of infection, or if dressing becomes loose/dislodge.

I. Perform dressing changes on short peripheral catheters if the dressing becomes damp, loosened, and/or visibly soiled and at least every 5 to 7 days. 3 (V, Committee Consensus)

[TexMurse]

Thank you, LovingLife123. I makes sense to me, but by chance do you have a reference that supports the practice?

[TexMurse]

NRSKarenRN, BSN, RN, thank you. I am familiar with the INS Standards and am trying to determine what "loose" means. What is your take?

[zoidberg, BSN, RN]

If you think you should reenforce the dressing, it’s time to change it. I don’t think you will find specific details like you are looking for, but I agree with the clear inner part of the dressing comment. You want the site and CHG/bio patch to be sealed well. Outer edges coming up a tiny bit is ok, but any peeling closer to the middle=time to change.

[NRSKarenRN, BSN, RN]

loose dictionary definitions:

a. not firmly held or fastened in place

b. not firmly or tightly fixed in place; detached or able to be detached.

So, if transparent dressing main section covering insertion site/bio patch is intact against skin but loose corner/edge of dressing is partially not attached to skin, I'll secure edge with tape/ another piece of transparent dressing.

Otherwise, I'll remove dressing, clean insertion site and apply another transparent dressing. Those clients with oil skin, sweaty or dressing just won't stick, apply skin prep to outer perimeter where edge of dressing will be (after cleaning site), let dry then apply new transparent dressing usually resolves coming loose.

?

[adventure_rn, MSN, NP]

All of my background is in NICU/PICU, but in my experience I think the definition of 'loose' depends on facility or unit standards; in some units, it even comes down to nursing preference, and isn't standardized at all (for better or worse).

I've worked on units where the moment the white edge peels up remotely close to the clear window, the entire dressing has to be changed; we were never allowed to simply reinforce the edge. I've worked on other units where we'd tolerate the clear window lifting and being non-occlusive so long as the CHG patch around the insertion site is intact and occlusive (I never personally felt comfortable with that, but you could ask any charge nurse, manager or provider on the unit, and they thought it was completely acceptable). Those are two radically different definitions of 'loose,' but they each represented a different unit-based practice.

I've worked in NICUs where only 'PICC nurses' (nurses trained to place PICCs) were allowed to redress them; you could ask two different PICC nurses to look at the same dressing on the same shift and get two different answers about whether or not the dressing was 'loose' and needed to be redressed.

I'm sure that isn't how things ought to be done (i.e. the process should be more standardized), but that seems to be the reality of the situation.

[TexMurse]

Thank you all for your help. I never thought I'd be the nurse who "gets in the weeds" of practice, but here we are. I have some good stuff to share thanks to you all!

[JBMmom, MSN, NP]

We recently received a message from IV therapy that central line dressings should never be reinforced with tape. I have also worked under the premise that as long as the main window was fully adhered, and the patch and site are centered, a little rolling of the white edges was acceptable in patients that are mostly immobile. However, in a patient that's moving around, as soon as the rolling starts, there's more of a possibility that the sticky exposed part will adhere to something else and the main portion will be dislodged with it.

[NurseDeveloper]

Hello, there is a fair chance you are talking about one of my dressings that I have either developed or directly work with.

I have spent a great deal of time discussing this topic with key opinion leaders throughout the world on my travels. The term loose was specifically chosen to be ambiguous. There is a reason why it is not defined specifically, primarily because we don't know.

What I can tell you is that;

• Timsit in 2012 demonstrated a much higher infection risk the more times you have an unanticipated dressing change.
• The studies that set the precedence for 7-day dressing changes are shakey at best and primarily driven by industry to find a standard timeframe.
• There is no existing evidence to demonstrate an ideal dressing size. A dressing the size of a quarter is literally as effective as a dressing the size of a pumpkin (regarding the viral and bacteria barrier properties).
• The "white border" is simply a border and not all companies extend their viral and bacterial barrier claims to that border. Bit of trivia, that white material is known as Sontara, a common non-woven material often seen in disposable gowns, pillows on airplanes, etc.

Personally, I agree with the comments regarding the adhesion of the window but it is my opinion only. This is a clinical opinion problem with no good answer. Change that dressing too often and the risk for infection goes higher. Dressing is falling off and the insertion site could be compromised.

Other things to consider;

• All vascular dressings have a direct path to the insertion site so as long as they are covering a catheter. There are no "occlusive" products on the market, the sheer variety of catheters means that there will always be a direct open path.
• There are and always be bacteria under the dressing, on the catheter, and in that insertion site. Sterility is a fiction. The best you can do is reduce the log count but know that bacteria is immediately growing the minute that prep dries, yes even with CHG.
• CHG dressings, patches, silver products, etc only help suppress regrowth but they do not sterilize the skin and yes bacteria is growing under those antimicrobial products. Question is how high of a log do they get to before you change the dressing.

[TexMurse]

This is impressive, NurseDeveloper. Thank you for your work in this space. The piece on the ambiguity on "loose" is fascinating.

I am happy to have put this thread out and to have so many nurses provide insights.