Central Line Maintenance

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Learning Objectives. Review the evidence and recommendations for central line maintenance. 2. Terminology for Lines Included. Percutaneously placed central linesTunneled lines Peripherally inserted central catheterVascular Access devices* May not include hemodialysis catheters. . 3. Source of R

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Central Line Maintenance

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1. David A. Thompson DNSc, MS, RN Central Line Maintenance/ Dressing Change

2. Learning Objectives Review the evidence and recommendations for central line maintenance

3. Terminology for Lines Included Percutaneously placed central lines Tunneled lines Peripherally inserted central catheter Vascular Access devices * May not include hemodialysis catheters.

4. Source of Recommendations Centers for Disease Control Society for Healthcare Epidemiology of America Infectious Diseases Society of America

5. Overview of Recommendations Central line maintenance recommendations address the following topics: Central line insertion Central line dressing changes Replacement of IV administration sets Hang time for parenteral fluids Catheter hub cleansing Removal of unnecessary lines Education

6. Central Line Insertion Ensure use of checklist Empower nurses to stop the procedure if the steps in the checklist are not followed Leadership must create a culture that supports nurses

7. Central Line Dressing Change Dressing change responsibility includes only those who have demonstrated competency: Nursing personnel including PICC teams and nurse practitioners Medical personnel including physicians and physician assistants

8. Frequency of Central Line Dressing Change Frequency: Transparent dressing Every 7 days PRN if damp, loosened, or soiled Gauze dressing Every 24 hours for routine use

9. Equipment Needed Chlorhexidine Gluconate 2% w/ Isopropyl Alcohol 70% (1 Swab)* * do not use if patient is sensitive Tincture of iodine or 70% isopropyl alcohol may be used. *do not use chlorhexidine in patients <2 years old. Sterile Gloves (appropriate size) Clean Gloves (appropriate size) Transparent dressing or gauze Mask for person applying dressing Cone mask for patient Skin prep Tape if gauze dressing is used

10. Additional Supplies that May Be Needed Sterile cotton tipped applicator (needed to cleanse insertion site) Sterile cup to hold sterile saline Sterile normal saline Adhesive removal pads or alcohol wipes Sterile 2x2 gauze

11. Procedure: Preparation Explain procedure to patient/family. Wash your hands. Don clean gloves and remove old dressing using alcohol swab or adhesive remover pads as needed. Inspect insertion site of catheter for signs of infection. Culture if needed. Assess security of sutures. Remove your gloves. Open sterile gloves and create a sterile field using sterile glove package.

12. Procedure: Sterilization

13. Procedure: Cleansing the Site

14. Preparing to Place Dressing

15. Placing the Dressing

16. Replacement of IV Administration Sets Lipids and blood products (enhance bacterial growth) Change every 24 hours All other IV administration sets No more frequently than every 72 hours Not more than every 96 hours

17. Hang Time for Parenteral Fluids Lipid-containing parenteral nutrition Change every 24 hours All other IV fluids including nonlipid-containing parenteral nutrition No formal recommendations JHH changes nonlipid-containing IV fluids every 24 hours

18. Catheter Hub Cleansing Clean hub before accessing with Chlorhexidine or 70% alcohol No formal recommendations regarding how long to cleanse hub

19. Remove Unnecessary Lines Assess need for continued central line access during daily multidisciplinary rounds Add question to a Daily Goals worksheet Complete every day during rounds

20. Education Educate all necessary staff: Guidelines to prevent catheter-related bloodstream infections Use of central line checklist Proper insertion and maintenance of central lines Ensure competency through yearly education and examination

21. WALK THE PROCESS When there is an infection...

22. Identify Barriers Ask staff about knowledge of prevention recommendations what is difficult about doing these behaviors Walk the process of staff placing a central line Observe staff placing central line

23. Audit Your Process Patient Level Was the check list used? Was the protocol followed? Did everyone wear appropriate clothing? Did someone speak up? Was the dressing secured? Was the site cleaned and maintained per protocol? Did you use a preferred site for placement? Did the line stay in longer than needed?

24. Audit Your Process Unit Level % of femoral lines versus IJ and SC? % of time the check list is used? % of time the protocol is followed? % of lines that should have been removed? How many nurses are comfortable speaking up? Did they? IS there support for the all the staff? Are lines changed out after emergent placement? Femoral preferred for renal caths because of sclerosis but not at risk if place IJ. Femoral preferred for renal caths because of sclerosis but not at risk if place IJ.

25. Review of tool Audit tool for Maintenance

26. References Johns Hopkins Hospital, Vascular Access Device Policy (Adult) http://safercare.s3.amazonaws.com/support_media/docs/clabsi/Appendix_H_Adult_VAD_Policy.pdf MMWR Guidelines for the Prevention of Intravascular Catheter-Related Infections http://www.cdc.gov/mmwr/PDF/rr/rr5110.pdf Marschall J, Mermel LA, Classen D, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals. Infection Control and Hospital Epidemiology. 2008; 29 (supp. 1):S22-S30. O’Grady NP, Alexander M, Dellinger P, et al. Guidelines for the prevention of intravascular catheter-related infections. Infection Control and Hospital Epidemiology. 2002; 23(12):759-769.

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