Question

Describe the guidelines for CLC dressing changes. What are the guidelines for flushing the CLC? Include routine and medication administration. Identify the nursing measures for removing a CLC or Peripherally Inserted Central Catheter (PICC).

Answer 1

CVC Maintenance Bundles

Central venous catheters (CVCs) can be in place from hours to weeks or longer and are manipulated by a multitude of staff members. CVCs are accessed many times while in place, to deliver fluids and medications and to collect blood specimens. Because each entry into access points in the delivery system is an opportunity to introduce microorganisms, the post–CVC insertion period presents multiple opportunities for risk of infection.

Almost 72% of all central line–associated bloodstream infections (CLABSIs) reported to the National Healthcare Safety Network (NHSN) by Pennsylvania acute care hospitals in 2010 occurred more than five days after insertion, suggesting that infection prevention lapses likely occurred in the postinsertion care and maintenance of the CVCs.1 Shapey et al. sought to assess staff members’ practice and knowledge of CVC postinsertion care in a tertiary care hospital, finding that lapses in proper infection prevention techniques occurred in 45% of postinsertion care episodes; the most common lapses were related to keeping caps and site dressings in place.

■Daily review of line necessity with prompt removal of unnecessary CVCs and documentation • Daily review of continued need for CVCs can be done in the following ways:

o During multidisciplinary patient care rounds
o By using reminders (such as stickers on patient records or order sets) o Via automated computer alerts

■ Details of removal documented in the records (including date, location, and signature and name of operator undertaking removal)

■ Details of removal documented in the records (including date, location, and signature and name of operator undertaking removal)

■Catheter injection ports

 Open lumens (such as stopcocks) are covered by injection ports, sterile end-caps or needleless connectors.

 Access ports are sanitized with alcohol, chlorhexidine/alcohol, povidone-iodine, and iodophors before and after each use, a method known as the “Scrub the Hub” protocol.

 Change gauze dressing every 2 days, clear dressings every 7 days (and more frequently if soiled, damp, or loose).

■Catheter access/manipulation

 Open lumens (such as catheter hubs or stopcocks) are covered by injection ports, sterile end-caps or needleless connectors.

 Catheter site care is performed with chlorhexidine at dressing changes.5 In the absence of chlorhexidine, use povidone iodine.

 Ports or hubs are cleaned using “Scrub the Hub” protocol prior to catheter access.

■Administration set (primary and secondary) replacement
 Set is replaced no more frequently than every 96 hours, and at least every 7 days, after initiation of use unless contamination occurs. This replacement interval is safe and permits considerable cost savings to health care organizations,6,3,7 with the following exceptions:
o Set is replaced immediately after administration of blood/blood products.
o Set is replaced after 24 hours following administration of infusates that enhance microbial growth (for example, fat emulsions combined with amino acids and glucose in three-in-one admixture or infused separately). 6,3,7
o Needleless components should be changed at least as often as the administration set and no more often than every 72 hours.

 The evidence is less clear for intravenous sets that are used intermittently, due to a lack of published research in this area.

■Infusate preparation using aseptic technique

■Health care personnel training
 All staff members manipulating CVCs could be required to attend a hands-on training class in the proper techniques for caring for and accessing catheters

followed by a competency evaluation of CVC insertion site and hub care.