Dressing disruption is a major risk factor for catheter-related infections. A large randomized controlled trial found that 67% of dressing changes were unplanned, and that dressing disruption directly correlates with increased risk of catheter colonization or infections. Johns Hopkins Hospital, pioneer of the original insertion line checklist, performed a root cause analysis in 2016 to determine if they could further decrease their already low CLABSI rate. Results from this analysis, coupled with a new “zero tolerance for blood” policy and a CLABSI reduction program that focused on getting back to basics, resulted in a 50% reduction in CLABSI in 2017, and an additional 26% reduction in 2018. This program will review the CLABSI reduction strategy, which focuses on dressing integrity and longevity, that worked for Johns Hopkins Hospital before, during and after the pandemic. It will explain evidence-based central venous catheter dressing change recommendations and outline strategies to ensure catheter dressing longevity in challenging situations.
Following a pre-insertion protocol that includes an assessment of patient-specific factors, along with choosing the right line and the right site for a successful insertion the first time can help mitigate infection risk. Dressings that are transparent, clean, dry, and intact decrease the risk of CLABSI and implementation of a zero tolerance for blood at the site takes the guess work out and leaves no room for individual interpretation of this definition. A comprehensive central line insertion checklist used in conjunction with all-inclusive central line kits has been shown to be a useful strategy in maintaining dressing integrity until the first scheduled dressing change, seven days from insertion.
Bloody dressings and dressing disruption are two major causes of CLABSI, so the integrity of the initial dressing placement is critically important. The best dressing is the first dressing; use a hemostatic agent at insertion to prevent bleeding lines instead of waiting to apply the hemostatic agent until after a dressing becomes bloody. To prevent bleeding at insertion, use a topical hemostatic dressing that forms a seal over the insertion site to stop the flow of blood and exudate, this protects the site from contamination, and keeps the site dry and intact until the scheduled dressing change. Adopting a “zero tolerance for blood” policy at the insertion site in combination with proper site preparation by the inserter and post-insertion care by a “Dressing Change SWAT Team” of experts is key to improving dressing longevity.
Proper dressing care and maintenance protocols help reduce infection risk and bundling supplies helps ensure compliance with these protocols. Pay attention to every detail. Perform dressing changes per your institutional protocol and secure the lines properly to prevent pistoning or too much tension. Form a “Difficult Dressing SWAT Team” to proactively address the most challenging dressing issues that can prevent the dressing from staying dry and intact and cause skin disruption. Encouraging and rewarding staff for being patient-centric can lead to the culture shifting adoption of a “zero tolerance for blood” dressing policy and the belief that a zero CLABSI rate is achievable.
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