Page 1 of 7 1. PURPOSE To provide a safe, standardized, evidence-informed process, for Central Vascular Access Device (CVAD) dressing changes. This practice guideline does not include dialysis catheters. 2. BACKGROUND The incidence of catheter-associated infections can be reduced by implementing recommendations adopted from authoritative bodies such as the Centers for Disease Control and Prevention (CDC), The Infusion Nurses Society (INS), and the Canadian Vascular Access Association (CVAA). 3. S 3.1 Aseptic technique is required for all CVAD dressing changes. 3.2 Dressing changes will occur at established intervals (dependent on type of dressing) and when necessary (PRN). These are: a) 24-48 hours post initial insertion if gauze dressing used b) Transparent semi permeable (TSM) dressing every 7 days and PRN. If there is bleeding, oozing, or signs of infection, use gauze, not TSM c) Gauze dressing, including gauze dressing under TSM, every forty-eight (48) hours and PRN. The catheter exit site is obscured by the dressing and must be visualized d) PRN includes, but is not limited to: dressing integrity is compromised; lifting, moisture, drainage or blood is present; or signs and symptoms of infection are present 3.3 Chlorhexidine Gluconate (CHG) greater than 0.5% with 70% Isopropyl Alcohol, is the preferred skin antiseptic agent. Tincture of Iodine, Iodophors (Povidone-Iodine) or 70% Isopropyl Alcohol may be used if there is a true sensitivity or allergy to CHG (see skin patch test Appendix A) 3.4 An adhesive-based Engineered Stabilization Device (ESD) may be used, and shall be changed when the dressing is changed or when signs of contamination/infection (debris from a lifted dressing, or bodily fluids) are present 3.5 At least once per shift within the hospital setting, and at each client care opportunity within the community setting, through the intact TSM dressing, the catheter exit site junction should be visually inspected for the presence of any abnormalities. The external portion of the catheter should be assessed for migration 3.6 Avoid the use of topical ointments, lotions, or creams at the catheter exit site. 3.7 Consult the hospital-based Vascular Access Team (VAT) clinician or, within the community setting the Clinical Educator (CIVP, CCMB) or if not available, a CVAA(c) nurse if there is evidence of catheter exit site and/or surrounding tissue complications 4. EQUIPMENT Dressings Antiseptic: One (1) CHG 2% with 70% isopropyl alcohol swab stick (or more if required); one povidone iodine swab stick (or more if required); or One 70% isopropyl alcohol swab stick (or more if required) One (1) sterile TSM dressing; or One (1) sterile package 4 x 4 Gauze dressing Medical adhesive tape if gauze dressing used.
Page 2 of 7 Tubular mesh of an appropriate size and length, to be used as a protective cover for Peripherally Inserted Central Catheters (PICC) Optional: culture swabs, protective skin barrier (for clients with adhesive sensitivity), sterile 2 x 2 gauze, sterile dressing tray, single use paper measuring tape (for measurement of the external catheter portion, to assess for migration), Supplies if Adhesive-based ESD Required: Adhesive-based Engineered Securement device 70% isopropyl alcohol pads Personal Protective Equipment (PPE) Non sterile gloves Sterile gloves Select and don appropriate additional PPE (e.g., face mask, eye protection), based on the risk of exposure to blood and bodily secretions or transfer of secretions to the insertion site and surrounding tissues 5.0 PROCEDURE 5.1 Preparation Identify patient/client using two identifiers Explain procedure and expected outcomes/risks to patient/client and family Perform hand hygiene Gather supplies Position bedside table or procedure cart to ensure both supplies and patient/client are within your field of vision throughout the procedure Within the home setting, ensure that there is a clean surface available on which to prepare and place supplies Special Considerations Patient/client or the designated decision maker should be provided education support so they have knowledge of the procedure, infection prevention practices, and the appropriate use of PPE 5.2 Perform hand hygiene 5.3 Don mask and eye protection if required Clients with symptoms of cold or flu should be encouraged to don a face mask and turn their face away from the exit site/dressing care as it is performed
Page 3 of 7 5.4 Assessment Visually inspect and palpate the catheter exit site for redness, swelling, and drainage. Note any patient/client complaints of tenderness or pain Palpate catheter pathway, noting any unusual swelling, redness, cording, or pain. Note external measurement (either by PICC catheter depth markings or tape measure) from exit site to the winged junction, to assess for catheter migration 5.5 Supply Preparation perform hand hygiene prepare supplies maintaining aseptic technique don non-sterile gloves 5.6 Removal of Dressing and Securement Device Partially remove the TSM in direction of exit site, exposing the securement device and leaving the catheter exit site covered Using the extension leg(s), gently lift catheter from the securement device Remove the adhesive-based ESD from the skin by applying 70% alcohol pad to the woven portion of the ESD, or as recommended by the manufacturer Remove the remainder of the TSM by gently peeling the dressing toward the catheter exit site Visually inspect the catheter exit site once the dressing has been removed. Hold the distal end of the catheter in your non-dominant hand for cleaning. If debris is present at the site: cleanse with sticks until debris is completely removed. Allow area to completely air. With a new stick, cleanse for 15 seconds applying friction, in back and forth motion. Reverse swab stick and repeat for another 15 seconds in opposing direction and then discard swab. Allow cleansed area to completely air. If debris is not present at the site: using Special Considerations May use sterile dressing tray. If not using sterile dressing tray, sterility of sterile items must be maintained May open the adhesive-based ESD mechanical doors through the TSM OR May release the adhesive-based ESD mechanical doors after the TSM has been partially removed, but leaving the catheter exit site covered Do not force removal of the securement device Use chlorhexidine in children under 2 months with extreme caution. Consider the use of an alternate antiseptic agent All tissues resting beneath the catheter, and which will rest beneath the dressing, must be cleansed Initiate cleaning at the insertion site and proceed outward with friction application method taking care to not cross over already cleansed insertion site.
Page 4 of 7 stick, cleanse for 15 seconds applying friction, in back and forth motion. Reverse swab stick and repeat for another 15 seconds in opposing direction and then discard swab. Allow the cleansed area to completely air Removal Without Securement Device Remove the TSM by gently peeling the dressing toward the catheter exit site Visually inspect the catheter exit site once the dressing has been removed. Note presence and effectiveness of securement suture if present. If debris is present at the site, cleanse with stick until debris is completely removed. Allow area to completely air. With a new, cleanse for 15 seconds applying friction, in back and forth motion. Reverse swab stick and repeat for another 15 seconds in opposing direction and then discard swab. Allow the cleansed area to completely air If debris is not present at the site, using stick, cleanse for 15 seconds applying friction, in back and forth motion. Reverse swab stick and repeat for another 15 seconds in opposing direction and then discard swab. Allow the cleansed area to completely air 5.7 Adhesive-Based ESD Application Perform Hand Hygiene Apply sterile gloves Lift extensions with sterile 4 x 4 gauze dressing and apply CVAD into ESD according to manufacturer s recommendations Remove protective tape covers from back of securement device. Apply to completely dried skin The amount of swab sticks used to clean, will be dependent on the amount of swab sticks required to fully remove all debris from the exit site, catheter, and surrounding tissues Do not blow on area, fan area or blot A dressing applied to damp tissues, increases the risk for skin complications. Special Considerations Skin preparation is used to reduce the risk of Medical Adhesive Skin Injury (MARSI), and should be considered for use on all clients The sterile strip supplied within the securement device package may be applied over the insertion site to prevent device migration during cleaning The use of a gauze dressing may prevent contamination of sterile gloves
Page 5 of 7 5.8 Dressing Application Place TSM dressing over exit site (DO NOT STRETCH) The TSM will be applied so the dressing extends a minimum of 2 cm in all directions from the exit site, covering both the catheter insertion site and the ESD. Ensure dressing covers securement suture if present. Entirely smooth the dressing outward from the exit site and then press to secure the edges. Ensure the notched edges of the dressing meet/overlap For PICC, note external measurement (either by catheter depth markings or tape measure) from exit site, to the point where the catheter enters the proximal end of the winged junction Mark the date and time of dressing change on the sterile tape included with dressing, and apply onto bordered edge of dressing. For PICC, may apply tubular mesh as a supportive cover Once the dressing application is complete, remove gloves and perform hand hygiene For polyurethane (or similar) CVADs, a straight pathway from the insertion site should be maintained For softer materials (silicone) a gentle J curve from the insertion site may be applied, with appropriate catheter length Ensure there are no kinks in the catheter Remove sterile securement tape after ESD has been affixed to the skin Stretching of the dressing during application can cause skin sheering and damage Do not use rolled gauze bandages with or without elastic, as it obscures device visualization, can impede circulation, and flow of infusate For dressing related complications see Appendix A 5.9 Documentation Documentation shall be accurate, factual, complete, legible, timely, accessible to qualified personnel and readily retrievable Include assessment measurements; performance of the procedure; type of antiseptic solution applied; dressing type; patient/client response to procedure; and any instructions given to the client
Page 6 of 7 Also include any noted concerns and abnormalities, any consultations, recommendations and follow ups 6.0. RESOURCES: Care of the Peripherally Inserted Central Venous Access Device (PICC), (June, 2015). Community Intravenous Program. Home Care Nursing Procedures Manual, Winnipeg, Manitoba Central Venous Access Device (CVAD): Dressing Change, (November, 2014). St Boniface General Hospital Nursing Procedure Manual, Winnipeg, Manitoba. Central Venous Access Device (CVAD) Dressing Change, (March, 2015). Centre-Wide Nursing Education Program, Health Sciences Centre, Winnipeg, Manitoba. Elsevier (2016). Central venous tunneled catheter: Dressing change (pediatric). Nursing Skills Online. http://mns.elsevierperformancemanager.com/nursingskills/contentplayer/skillcontentplayeriframe.aspx?keyi d=870&id=ccp_143a§ion=1&bcp=searchop~0~tunneled%20central%20line~false&isconnect=false Elsevier (2016). Peripherally inserted central catheter: Maintenance and dressing change. Nursing Skills Online. http://mns.elsevierperformancemanager.com/nursingskills/contentplayer/skillcontentplayeriframe.aspx? KeyId=10719&Id=GN_44_11&Section=1&bcp=SearchOp~0~central%20vascular%20access%20device~False &IsConnect=False Perry, A., Potter, P., & Ostendorf, W. (2014). Intravenous and Vascular Access Therapy. In Clinical Nursing skills & Techniques (8th ed., pp. 697-724). St. Louis: Mosby. Winnipeg Regional Health Authority (2016) 5.10 Wound Care. Home Care Nursing Procedures Manual. http://home.wrha.mb.ca/prog/homecare/manuals_npm.php 7.0. REFERENCES: Center for Disease Control and Prevention (2011). Guidelines for the Prevention of Intravascular Catheter- Related Infections. Department of Health and Human Services. Retrieved from: http://www.cdc.gov/ hicpac/pdf/guidelines/bsi-guidelines-2011.pdf Infusion Nurses Society (2010). Infusion Nursing: An Evidence-Based Approach (3 rd ed.). M. Alexander, A. Corrigan, L. Gorski, J. Hankins, & R. Perucca (Eds.). St Louis MO: Saunders Elsevier Infusion Nurses Society (2016). Infusion Therapy Standards of Practice. Journal of Infusion Nursing Norwood, MA: Wolters Kluwer Infusion Nurses Society (2016). Vascular access devices: Ongoing assessment, site care, and dressing change. Policies and Procedures for Infusion Therapy (5 th ed.). Norwood MA: Publisher, Infusion Nurses Society
Page 7 of 7 Appendix A Managing Peripherally Inserted Central Catheter Dressing-Related Complications If Hospital-based VAT Clinician or Community-based Program Educator (e.g. CIVP, CCMB), CVAA(c) nurse is unavailable for consultation, follow below to guide problem solving. Ensure the Hospital-based VAT Clinician or Community-based Educator, is notified of skin-related complications associated with CVAD. Skin Irritation/Contact Dermatitis/Pruritis 1.0 Conduct a Skin-Patch Test Apply 2% chlorhexidine (CHG) w/70% alcohol to forearm of the opposing arm. Monitor for reaction, for a minimum of fifteen (15) minutes. Apply a TSM dressing to an area of the opposing arm (not over area cleansed with skin antisepsis) and monitor for reaction. 2.0 Once a reaction to CHG with alcohol has been confirmed by skin patch test: Try Povidone Iodine, applying per manufacturer s recommendations. **Note, prior to application of Povidone Iodine, site must be cleansed well with either 70% Isopropyl Alcohol pad or sterile normal saline, to remove the other cleanser. If irritation/dermatitis continues, try sterile normal saline until condition resolves. 3.0 For dressing related skin irritation or MARSI, consider gauze dressing. Note, gauze dressing MUST be changed every 48 hours. Primary Authors: Tara Schmitz Forsyth RN BN CVAA(c), Clinical Nurse Educator, Home Care Community IV Program Nancy Friesen RN CVAA(c), Vascular Access Clinician, St Boniface General Hospital Mary Lou Waschuk RN BN, Vascular Access Nurse, Grace General Hospital Cathie Hutfluss RN BN, Vascular Access Nurse, Victoria General Hospital Gisele Sarbacher RN BN, Nurse Educator Oncology, Victoria General Hospital Sandra Lang-Donald RN BN, Manager, Grace General Hospital Karen Braun RN BN, Educator CancerCare Manitoba, St Boniface Hospital Cathy Torchia RN, Cancer Care Manitoba