Central venous catheters (CVCs), central lines, are intravascular access devices that are

placed under sterile conditions for the purpose of administering life-saving medications in

critically ill patients. CVCs may be indicated when a patient requires ​medications that have a

vesicant property, the administration of multiple medications simultaneously, in patients with

poor intravenous access, or patients that require frequent blood draws. While the placement of

CVCs occur under sterile conditions, the prolonged use of the central line poses an increased risk

for acquiring blood stream infections. Fifty-one percent of hospital acquired bloodstream

infections are directly related to patients in the intensive care unit (ICU) that have CVCs (The

American College of Radiology, 2017). Central line-associated bloodstream infections

(CLABSIs) are preventable occurrences with the use of proper protocols, infection control

measures and the implementation of evidence based practice methods. The Center for Disease

Control and Prevention (2011) has a detailed checklist for the prevention of CLABSI with

mention about sterile dressing changes and recommendations for the interval changings of

certain CVC dressings, however, there is no standardized type of dressing. Various dressing

types were analyzed through literature review of evidence based practice, and the formation of a

PICOT research question to ascertain if impregnated dressings reduced infection rates in patients

with central lines.

PICOT Question

The PICOT formula, which accounts for population, intervention, comparison, outcome

and timing, was used to frame a research question regarding the use of central line dressings. The

population of interest was adult patients within the ICU that had CVCs placed on admission. The

intervention included the use of impregnated, sterile dressings. The comparison was two-fold, in
terms of comparing the Biopatch impregnated disc to the CHG (chlorhexidine gluconate)

Tegaderm dressing, with a comparison of sterile, non-impregnated dressings to impregnated

(Biopatch and CHG tegaderm) sterile dressings. The outcome was that the use of CHG infused

dressings would diminish infection rates in ICU patients when compared to traditional dressing

types. The timing for research would account for all ICU patients over a three month timeframe.

Following the breakdown of the PICOT method, a formal question was developed: In adult ICU

patients, what is the effect of CHG infused CVC dressings on CLABSI rates compared with

traditional (non-impregnated) CVC dressings within a six month time frame.

Literature Review
A comprehensive literature review was performed to analyze the effectiveness of CVC

dressing types and formulate evidence based theories to standardize the use of CVC dressings.

The literature review contained articles under the search for central line-associated infection,

CLABSI, CVC dressings, Biopatch, CHG impregnated dressings. Further descriptive wording,

such as comparison versus, infection rates, and sterile, were used to refine the search for articles.

The search resulted in hundreds of articles which were reviewed of which five articles were

deemed most poignant to the PICOT question.

Most nurses that practice within the ICU do not think twice about the use of CHG infused

CVC dressings, however, it is not defined as a standard of practice (Mahjoub, & Dupont, 2014).

The Center for Disease Control and Prevention (CDC) guidelines do not define a standard

practice for dressing types, and even make mention of “gauze” dressings. The health care market

offers numerous types of dressings and depending on facility protocol and preferences there

could be drastic variation in the type of CVC dressings that are used.
 Safdar, O’Horo, Ghufran, Bearden, Eugenia Didier, Chateau, & Maki (2014) performed a

quantitative meta-analysis study to assess the infection rates in patients with

chlorhexidine-impregnated dressings for prevention of CLABSI. The patients in the treatment

group, which included chlorhexidine-impregnated dressings, had an incidence rate of 1.2%

compared to 2.3% in the comparative group. The use of chlorhexidine-impregnated dressings

was found to be effective in preventing central line- associated infections, displayed limited

microbial resistance and proved cost effective. The authors estimated the cost for use of CHG

dressings to be $18 with the cost of preventing a CLABSI estimated to be $2,106. While the cost

to treat a CLABSI was estimated at $11,971. This study proves to be one of the most

comprehensive reviews of impregnated CVC dressings but is limited in its review because it

offers no evidence from double blinded studies. Based on the findings, one can conclude the

CHG dressings substantially reduced central line-associated infections but do not account for the

lack of a standardized process for performing dressing changes. (Safdar, et al., 2014).

A study with 106 participants that had a peripherally inserted central catheter (PICC)

were randomized to study the infection rates when comparing a CHG-impregnated dressing to a

polyhexamethylene biguanide (PHMB) disc dressing (Webster, Larsen, Marsh, Choudhury,

Harris, & Rickard, 2017). The study found that 2% of the population, one each for the CHG and

PHMB group acquired a line-associated infection. The study defines the dressings safe for use

with proven effectiveness in decreasing line-associated infection rates but makes no mention of

other variables, or dressing options, that could have been used for comparison.

Regardless of dressing type, the majority of CLABSI cases are attributed to normal

microbial flora that resides on the skin. The premise of the infused dressings is to block
microbial access at the insertion site. In order to comprehensively maintain the insertion site, the

dressing must be maintained with proper adhesion to the skin. Timsit, Mimoz, Mourvillier,

Souweine, Garrouste-Orgeas, Alfandari, Plantefeve, Bronchard, Troche, Gauzit, Antona, Canet,

Bohe, Lepape, Vesin, Arrault, Schwebel, Adrie, Zahar, Ruckly, Tournegros, & Lucet (2012)

performed a randomized study comparing infection rates in CHG dressings versus highly

adhesive (nonchlorhexidine) dressings. The thought behind the study assumed that CLABSI rates

may be related to dressing integrity without consideration for antimicrobial additives. The highly

adhesive, nonchlorhexidine dressing group showed an increase in skin and catheter colonization

but decreased CLABSI by 60%. The CHG dressing group displayed a 67% decrease in infection

with decreased skin and catheter colonization. The study does make mention of the locations of

the CVCs, but offers minimal correlation to location and infection rates when comparing the two

dressings. The use of CVC in the femoral or internal jugular are typically more prone to infection

and the study should have offered statistics to confirm that the CHG group outperformed the

non-CHG group, regardless of line location (Timsit, Mimoz, Mourvillier, Souweine,

Garrouste-Orgeas, Alfandari, Plantefeve, Bronchard, Troche, Gauzit, Antona, Canet, Bohe,

Lepape, Vesin, Arrault, Schwebel, Adrie, Zahar, Ruckly, Tournegros, & Lucet 2012).

In order to perform a fair analysis, literature that disputed the use of CHG dressings were

analyzed. Two articles were found to claim no difference in infection rates between populations

that utilized CHG dressings and populations without CHG dressings. Uppanisakorn, Pochanakij,

Boonyarat, & Bhurayanontachai (2015) analyzed 380 total patients in the ICU with 453 total

catheterizations and found that infection rates in patients with CHG dressings was 1.19% and

1.7% in patients without CHG dressings. The study limits its sample groups in the non-CHG
group to only 117 patients while there are almost three times that, 336 patients, within the CHG

group. The study results may vary if the population sizes are leveled. The study fails to mention

location and percentages for line placements, which also may impact infection risk/rates within

the population. Schoeder, Jacobs, Guite, Gassner, Anderson, & Donnelly (2012) also dispute the

claim that CHG dressings reduce bacterial colonization on invasive line insertions. While the

study correlates CVC and PICC placements with CHG use, it actually assess infection rates

within a population of patients with femoral nerve catheters FNC. Although the catheter types,

locations, and maintenance differ from CVCs, the premise of sterile insertion and preservation

remain the same. The study concluded that bacterial colonization rates were lower in

non-Biopatch patients (4.3%) compared to patients with the Biopatch (6.3%). While the premise

of FNCs is the same as CVCs, the duration of treatment is drastically different. The majority of

FNCs are used for a couple days, while some CVCs remain in place for days, weeks, and even

months. The infection rates may be drastically different if the study was performed over a longer

period of time. Also, many infection control methods define the femoral site is the highest risk

for infection, at least for CVCs so it was interesting that the FNC site had a lower infection rate,

regardless of duration.

Evidence Based Practice Model

Without a recommendation from the CDC for which type of dressing should be to cover

central lines, the decision was made to use CHG impregnated dressings in the ICU over a 3

month time period and has any effect with decreasing CLABSIs. The model that was chosen to

help implement the best practice change was the Iowa Model of Evidence-Based Practice. This

model uses 7 steps to provide guidance for nurses and other clinicians in making decisions that
affect patient outcome. The first step is to identify a “trigger” or a problem that is in need of

change (Dang, Melnyk, Fineout-Overholt, Ciliska, DiCenso, Cullen, Cvach, Larrabee,

Rycroft-Malone, Schultz, Stetler, Stevens, 2015, pp. 283-287). The “trigger” was identified as an

unacceptable number of CLABSIs being reported each year. All central lines that are placed in

the ICU during the 3 month trial will be documented no matter the location of the line and for

how long it is in use. Step two is clinical application (Dang et al). Nurses and other clinicians

will have a direct role with ensuring the use of CHG impregnated dressings, gathering data when

infections are noted, and teaching other staff members proper dressing change protocols. Step

three is identifying if the practice change is a priority to the organization or not (Dang et al).

With patient care at the center of hospital core values, the need to establish safe practice to help

prevent central line infections was agreed by all team members to be a high priority. Any

practice change that can be implemented to promote patient safety and decrease the length of

stay for all patients is of the highest importance. Step four is formulating a team (Dang et al). To

help implement the change in practice and oversee the transition, the CNO, ICU director, and

charge nurses have been selected as the leaders of the team. The CNO will ensure that proper

funds are being delegated to the ICU for necessary supply purchases such as, changing out the

current supplies in the ICU, ordering expenses, and unit education for the new product. The ICU

director will be in charge of making sure the CHG impregnated dressings are ordered and

stocked in the supply room and that all other central line dressings are removed from the unit.

The director will also implement a schedule for mandatory training for the new dressings to

ensure all staff are aware and comfortable with the new equipment. The charge nurses will make

sure that each patient with a central line has the appropriate dressing intact with a date and time
the dressing was placed. Any dressings that are noted to be loose or soiled will be changed

immediately by the primary nurse or charge nurse if needed. Nurses will be responsible for

making sure all dressings that are applied to new and old central lines are the CHG impregnated

dressings. This must remain intact and unsoiled while the patient has the central line. Any

dressings that are soiled or loose will be replaced by the primary nurses or the charge nurse. Step

five is piloting a practice change. The ICU was selected to pilot the CHG impregnated dressing

before going live throughout the entire hospital due to the high patient acuity and frequency of

central line use. Another reason for the ICU being selected as the pilot unit was mentioned above

with 51% of hospital acquired infections being related to patients in the ICU with central lines. If

the number of infection rates decreases in the ICU with the use of CHG impregnated dressings,

the dressings will be implemented throughout the remaining units of the facility. This leads us to

step 6, evaluating the pilot. The CHG dressing will be used and data will be collected for a three

month time frame as designated by the facility and its team. After which all data will be analyzed

to see if there was a decrease in the rate of CLABIs or not. Data will be analyzed and the need to

discuss whether or not to use a different type of dressing if the infection rate numbers did not

change will be evaluated. If the process should be changed, items such as increasing the time

frame for data collection, changing dressing type, or if the process should be cancelled altogether

from a lack of evidence for improvement will be evaluated. This leads us to our last and final

step. Evaluating practice change and dissemination of results. Once the pilot phase has been

completed and data shows the change in practice to be effective, the change will be implemented

throughout the facility. Other units in the facility that frequently deal with central lines will

incorporate the new dressings and dressing change standards. Data will continue to be collected
per hospital policy to record CLABSI rates and further change will be made to find additional

changes must be made to lower the risk of CLABSIs even further.

Guiding Nursing Theory

Imogene King’s Theory of Goal Attainment was used to help guide the team during the

practice change and implementation of a standardized dressing for central lines. King’s theory

involves personal, interpersonal, and social systems. Imogene believed that the focus of nursing

was to care for the human being which falls under the personal section of her theory (Smith,

Parker, Sieloff, & Frey, 2015). While a patient is in the ICU, every member of the care team has

the same goal which is to ensure the best possible outcome for the patient. By providing the best

evidence based practice during hospitalization, the risk of central line infection decreases and the

best outcome for the patient increases. The team in charge of taking care of the patient is part of

the interpersonal system described by King. The team works directly with the patient and staff to

provide education and encouragement to achieve the goal of lowering CLABSI rates in the

hospital. Patients that are alert and oriented can assist the nurses and team leaders by following

instructions during dressing changes and notifying the primary nurse of any concerns or loose

dressings. They are able to be a part of the care plan process and create attainable goals with the

staff using the transaction process of King’s theory. King’s theory also provides information

about the nursing process of assessment, nursing diagnosis, planning, implementation, and

evaluation. This is used to identify patient specific problems but can be applied to improve

clinical practice as well. The team implements the nursing process to provide the best possible

care for the patient by assessing the need to change clinical practice in order to decrease central

line infection risk. The team applies the diagnosis step by recognizing that the type of dressing
used to protect insertion sites may be a factor. A plan is created and the team has agreed to use

the CHG impregnated dressing during a 3 month time frame. Data will be analyzed to establish if

the measure was effective or not in reducing infection rates associated with central lines. The

team uses this theory to identify goals that are attainable and centered on improving patient

outcome. Research is gathered and studied to find evidence based best practice methods that

have been shown to decrease infection rates with central line use. King’s method provides a solid

foundation for helping evaluate and improve clinical practice that impacts patient outcomes.

Conclusion

Invasive lines are placed in hopes of treating severely ill patients and to assist them in a

more effective recovery process. When improperly taken care of, these lines have the potential to

do the opposite. Even though central lines are placed under sterile conditions, central line

associated infection will always be a risk to patients and a challenge to healthcare facilities. ICU

patients remain the most vulnerable for CLABSI, therefore steps need to be taken to ensure that

all methods to prevent infections have been taken. Nurses are directly responsible with making

sure a patient remains safe while a central line is in place. Through daily observation of clinical

practices that work and do not work, nurses are able to provide first hand experience and

facilitate practice changes in the facilities in which they work. Through evidence based practice

and a continued desire to improve patient outcomes, CLABSI rates throughout the world should

continue to decrease as new measures are taken to protect the patient. Using CHG impregnated

dressings is one step to ensure patients with central lines are being protected from the possibility

of infection.
http://www.idhjournal.com.au/article/S2468-0451(16)30102-X/fulltext
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