Central Line Dressing Changes part of IV Team Responsibilty
Are most IV Access Teams taking on central line dressing changes for continuity of care and maintenance particularly with the CMS reimbursement issue coming in Ocotber?
We have always done them. I have been placing PICCs since 1989 on the same team. We have insisted that we perform routine and the majority of prn dressing changes. We tried twice to allow the SNF associated with the hospital to perform dressing and cap changes (only b/c we had to leave the building and it took more time than we had). We ended up taking them back b/c of late recognition of complications, higher infection rate, inadequate dressing changes and we had a big problem of the nurses pulling out a couple of cms every time they did a dressing and we kept having to re-site them. This was even with training.
All teams where I have worked have always (and still do) perform all CVC dressing changes. We can not allow all hands on these devices if we expect to maintain a high standard of continuity in our procedures. Lynn
If you are collecting good QA/PI data, doing the dressings can make it a lot easier. You'll always know when a patient has been discharged. With the dressing change also comes a good assessment by your vascular access experts. This can prevent false alarms and catch issues before they become to serious.
Our IV team monitors daily and changes weekly all central line dressings; PICCs, IJs, Dialysis, femoral, etc. At one time the hospital tried to give that work back to the bedside nurses and did extensive training with them. We had the same results as other have; increased infection rates, dislodged lines, poor dressings.
I know this may seem like a silly question/response, but I work in a large facility with a new bedside picc team (we are almost 3 years old). We only have 2 team members on our picc team and in order to provide the most amount of coverage in a week, we do 12 hour shifts from M-F (no weekends or holidays), hence only one of us is here each day except on Wednesdays when we overlap. While we are highly respected by our facility for our skills and knowledge regarding CVAD - especially picc lines, we can not keep up with the demands on the troubleshooting and care of these lines. We have done extensive education to our staff but are seeing some of the same problems that you have mentioned in your postings (lines pulled, dsg not changed when it should, improprer assessment of site, increased complete occlusions of catheter etc).
What suggestions do you guys have for a team such as ours. I feel like we are a very successful team, but I worry about the aftercare on our lines and try to follow those we can, but with the number of piccs we do in a month (about 120 - 125) it is getting very difficult. I am sure that one of your answers will be to approach Admin and request a larger team - been there, done that. Until I can convince them I need some good suggestions from those of you who have been in this situation.
You need data in the form of dollars the present system is costing your facility - lost lines, complication treatments, etc. Then compare this to the improved outcomes and the cost for your expanded team to do these procedure in an expanded role. Until you put this in financial terms, it will not mean anything to your management. This will take time to compile and it sounds like you do not have the time. So that means you will need help from others in your hospital or hire a consultant. You need to work with your costs, your patient numbers, etc. There are formulas and use your internal figures. So this will be more than just suggestions from others. This must be a business approach to show that what you are proposing will produce better outcomes that will contain cost. Note this is not about increasing patient charges - that does not work in this day of capitated fees. It is about ways to reduce your cost, allowing the hospital to retain a greater portion of your capitated fee being received. Also 3 of the first 8 complicating conditions that will no longer be paid for (CMS rules beginning 10-1-08) are infuison related - CRBSI, air emboli, and blood incompatability. What is the incidence of these complications in your facility? If high, the costs of treated these conditions will not longer be paid. So a higher level of knowledge and skill is required to prevent these complications from happening. This means expansion of your team. Hiring a consultant may not be in the budget either, but let me know if I can offer anything. Lynn
I work at a hospital that with an avg. daily census of 260. We place 130-150 picc's /month. We have an invasive line care tech that does all of our PICC dressing changes for us. Our infection rates are extremely low. I can not provide you with a buisness plan on how to justify the position as that was not required of us prior to hiring her. She also assists the PICC nurse with insertion and does audits on PICC dressings as time allows. She is a HUGE asset to our team. Feel free to email me privately if you would like more info. email [email protected]
Karen Ratz,RN, VA-BC Unity Point St. Lukes Hospital, Cedar Rapids,IA
I just came across this thread searching for research that proves the superiority of IV Teams for delivering IV care. I have the MMWR from the CDC in 2002 that states "Specialized 'IV Teams' have shown unequivocal effectiveness in reducing the incidence of catheter-related infections and associated complications and costs." It lists three references for this that I am having difficulty locating because they are so old (1980, 1985, and 1998). I am writing a proposal for a research utilization project in my master's program, and I need to find support for this. I know Lynn and Kathy probably have more current data available. Can any of you help me? Thanks
We're so fortunate to have a relatively large 24/7 IV Therapy team, and so we do 90% of the nontunneled and tunneled central line dressing changes, and 100% of the PICC dressing changes. Oncology and ICU staff do their own except for PICCs. From the look on one of the nursing administrator's faces when someone asked if the staff nurses would start doing more CVAD dressing changes, I doubt that this will change.
Mari Cordes, BS RN
Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
I am a clinical eduator at a hospital without an IV therapy team . We are revamping our policies with regards to PICC dressing changes and a question has come up regarding the statlock anchoring device. We change our dressings @ 24 hours post insertion and then every 96 hours..but there is a variety of practice when it comes to changing the stat lock. I have researched INS but the info is vague.Could anyone share what other hospitals are doing? and does every one use some sort of an achoring device?
First, I will tell you that I am a consultant and speaker for Bard Medical, the manufacturer of Statlock.
The first question to investigate is the amount of bleeding that is being seen within the first 24 hours around the PICC insertion site. This practice originated from the older methods of insertion that used an introducer needle larger than the PICC that was left in the vein. The current insertion methods do not have as much bleeding. So if bleeding is not an issue following PICC insertion, you can stop doing the dressing change at 24 hours. You can also change all CVC dressing change policies to a once per week change interval. I have recently seen a new publication about this, but will have to go through a stack of new stuff to locate it. I will post it on my blog when I find it.
RE the change of all manufactured catheter stabilization devices - you should be following the instructions from the specific manufacturer of the product being used. There are several products available now and they could have different instructions for use. The INS standards do state that a manufactured catheter stabilization device is preferred over other methods of stabilization such as sterile tape or wound closure strips. Published outcomes are far better with these devices. The instructions for Statlock state that this should be changed at least every 7 days and with each dressing change. This device has a coating that allows for easy release of the transparent dressing from the Statlock. Removing the dressing also removes this coating. If the Statlock is not changed with each dressing change, you will not have the benefit of this coating for the second dressing change, making it difficult to separate the dressing from the Statlock. Also, there is no way to adequetely clean the skin without removing these stabilization devices.
Hi, We use the stat lock and like it very much. We tried the Bone and found it to cumbersome. We change our dressings in first 24 hrs and then 7 days or prn. We do all the cld for the hospital. I would really like to have the MD place a stat lock on subclavian and IJ lines, I hate those sutures. Lynn, do you think the stat lock would work for those lines also? TY
Yes, there are designs of Statlock that is intended for use with all types of catheters, along with some outcome data published on these catheters. See
1. Frey A, Schears G. Why are we stuck on tape and suture? Journal of Infusion Nursing. 2006;29(1):34-38.
As a PICC nurse in a small hospital with only one nurse on a day we have a different approach that most stated here. We change the initial 24 hour dressing and apply the TegaDerm with CHG. All other dressing are changed by the staff. We have done this for over a year and have not have an increase in line infections. Last, count was one documneted infection in the past 9 months. We are only here 5 days a week and only one nurse. There is no way we can do all dressing. When we had 2 nurses on it could have been possible but not now with budget cuts.
Some days if I have 5 or 6 PICC's to place I have to call the floors to change the initial dressing. It does take contining education and monitoring, but as I said we have NOT had an increase in infections.
There are 5 in our Vascular Access Team, with usuallly 2 on shift at a time. We generally have between 30 and 50 central lines. We do not place PICCS, but at this time we round on all central lines and do all dressing changes,place midlines and US guided IVs. We use the Bard Statlock and a CHG gel dressing ( I think it's 3M?). Our Interventional Radiology team places the PICCs. We did a trial of having IR place the CHG dressings at the time of insertion and found that it was very successful. The need for the 24hr dressing change freed up our time so we could assess every CL in house every day.We now have the docs placing the CHG gel dressing on the cordis IV that is placed for open heart. This has increased patient satisfaction,especially on the IJs because we don't have to do an uncomfortable dressing change on an IV that will only be in for another day or 2.
We are a smaller hospital and insert 60-70 PICCs per month with one PICC RN daily and no IV therapy team. We have been working hard to try to convince administration that we have to be in charge of the after care of our PICC lines but they only are interested in the daily average number of insertions. We recently have started doing QA on all the PICCs and writing a report for those that do not get changed, getting pulled out and not getting declotted per policy. We have an average of 12-15 lines in house at any given time. I am getting very frustrated because the administration is just pushing us to do more and more and not accepting the fact that the nurse inserting the lines for the day can only get to the insertions and there is no time left or dressing changes. Is there anything else that we can be doing to convince them?
Denelle Oliveros RN, CRNI
Nurse Manager
University Option Care
Columbus, Ohio
We are a vascular access team of 3. We work 12 hour shift so occasionally we have 2 on at a time but most of the time there is just 1 of us. 2 employes are full time one is part time. We cover the department 7 days a week and we are on call from when we leave for the day until the next day when the next person comes in. We insert all the PICC lines we do anywhere from 80-100 a month and we do daily rounds on all central lines and picc lines, we do also change all the dressings on all the lines and change all the endcaps every 4 days. We start our day at 6 am and start rounding then so we are done with our rounds usually before we start getting picc consults then we chart all of our rounds and start insertions. Sometimes it is overwhelming especially when the amount of lines we round on are up and we get 8 or more consults in a day but we like taking full reponsiblitiy for them, usually we round on 50-60 central lines in a day.
I have been asked to come up with a reason to NOT go to same-day-of-the-week central line dressing changes. We change at 24 hr post-isertion only if there is blood on the Biopatch present. We then go to weekly changes based on whatever day of the week it is. Our management wants all dressings done on the same day & I have to justify why we don't want that.
Anyone have input? INS doesn't have anything I can find addressing this issue.
Rene Maslow, RN, CRNI
Kaiser Santa Rosa PICC/Procedure RN
ReneMaslow, MSN, VA-BC PICC/Proc RN Kaiser Permanente Santa Rosa, CA
We have always done them. I have been placing PICCs since 1989 on the same team. We have insisted that we perform routine and the majority of prn dressing changes. We tried twice to allow the SNF associated with the hospital to perform dressing and cap changes (only b/c we had to leave the building and it took more time than we had). We ended up taking them back b/c of late recognition of complications, higher infection rate, inadequate dressing changes and we had a big problem of the nurses pulling out a couple of cms every time they did a dressing and we kept having to re-site them. This was even with training.
Thanks for the feedback Mary Ann, I am trying very hard to bring this care back to our IV Team.
Kevin
All teams where I have worked have always (and still do) perform all CVC dressing changes. We can not allow all hands on these devices if we expect to maintain a high standard of continuity in our procedures. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
If you are collecting good QA/PI data, doing the dressings can make it a lot easier. You'll always know when a patient has been discharged. With the dressing change also comes a good assessment by your vascular access experts. This can prevent false alarms and catch issues before they become to serious.
Mike Brazunas RN
Clinical Specialist
AngioDynamics
Our IV team monitors daily and changes weekly all central line dressings; PICCs, IJs, Dialysis, femoral, etc. At one time the hospital tried to give that work back to the bedside nurses and did extensive training with them. We had the same results as other have; increased infection rates, dislodged lines, poor dressings.
Greg Bowman, RN
Clinical Supervisor, IVT
Swedish Medical Center
Thanks all for the feedback.
Kevin
I know this may seem like a silly question/response, but I work in a large facility with a new bedside picc team (we are almost 3 years old). We only have 2 team members on our picc team and in order to provide the most amount of coverage in a week, we do 12 hour shifts from M-F (no weekends or holidays), hence only one of us is here each day except on Wednesdays when we overlap. While we are highly respected by our facility for our skills and knowledge regarding CVAD - especially picc lines, we can not keep up with the demands on the troubleshooting and care of these lines. We have done extensive education to our staff but are seeing some of the same problems that you have mentioned in your postings (lines pulled, dsg not changed when it should, improprer assessment of site, increased complete occlusions of catheter etc).
What suggestions do you guys have for a team such as ours. I feel like we are a very successful team, but I worry about the aftercare on our lines and try to follow those we can, but with the number of piccs we do in a month (about 120 - 125) it is getting very difficult. I am sure that one of your answers will be to approach Admin and request a larger team - been there, done that. Until I can convince them I need some good suggestions from those of you who have been in this situation.
thank you in advance for all of your help.
karen
You need data in the form of dollars the present system is costing your facility - lost lines, complication treatments, etc. Then compare this to the improved outcomes and the cost for your expanded team to do these procedure in an expanded role. Until you put this in financial terms, it will not mean anything to your management. This will take time to compile and it sounds like you do not have the time. So that means you will need help from others in your hospital or hire a consultant. You need to work with your costs, your patient numbers, etc. There are formulas and use your internal figures. So this will be more than just suggestions from others. This must be a business approach to show that what you are proposing will produce better outcomes that will contain cost. Note this is not about increasing patient charges - that does not work in this day of capitated fees. It is about ways to reduce your cost, allowing the hospital to retain a greater portion of your capitated fee being received. Also 3 of the first 8 complicating conditions that will no longer be paid for (CMS rules beginning 10-1-08) are infuison related - CRBSI, air emboli, and blood incompatability. What is the incidence of these complications in your facility? If high, the costs of treated these conditions will not longer be paid. So a higher level of knowledge and skill is required to prevent these complications from happening. This means expansion of your team. Hiring a consultant may not be in the budget either, but let me know if I can offer anything. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Karen Ratz,RN St. Lukes Hospital, Cedar Rapids,IA
I work at a hospital that with an avg. daily census of 260. We place 130-150 picc's /month. We have an invasive line care tech that does all of our PICC dressing changes for us. Our infection rates are extremely low. I can not provide you with a buisness plan on how to justify the position as that was not required of us prior to hiring her. She also assists the PICC nurse with insertion and does audits on PICC dressings as time allows. She is a HUGE asset to our team. Feel free to email me privately if you would like more info. email [email protected]
Karen Ratz,RN, VA-BC Unity Point St. Lukes Hospital, Cedar Rapids,IA
Kathy Kokotis
Bard Access Systems
I would say the answer to that question will have more light shed on it in 2009 after the CMS changes occur
kathy
Kathy Kokotis
Bard Access Systems
I just came across this thread searching for research that proves the superiority of IV Teams for delivering IV care. I have the MMWR from the CDC in 2002 that states "Specialized 'IV Teams' have shown unequivocal effectiveness in reducing the incidence of catheter-related infections and associated complications and costs." It lists three references for this that I am having difficulty locating because they are so old (1980, 1985, and 1998). I am writing a proposal for a research utilization project in my master's program, and I need to find support for this. I know Lynn and Kathy probably have more current data available. Can any of you help me? Thanks
Jerry Bartholomew RN, BSN, CRNI
VA Medical Center, Spokane, WA
Jerry Bartholomew RN, MSN, CRNI
VA Medical Center, Spokane, WA
We're so fortunate to have a relatively large 24/7 IV Therapy team, and so we do 90% of the nontunneled and tunneled central line dressing changes, and 100% of the PICC dressing changes. Oncology and ICU staff do their own except for PICCs. From the look on one of the nursing administrator's faces when someone asked if the staff nurses would start doing more CVAD dressing changes, I doubt that this will change.
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
I am a clinical eduator at a hospital without an IV therapy team . We are revamping our policies with regards to PICC dressing changes and a question has come up regarding the statlock anchoring device. We change our dressings @ 24 hours post insertion and then every 96 hours..but there is a variety of practice when it comes to changing the stat lock. I have researched INS but the info is vague.Could anyone share what other hospitals are doing? and does every one use some sort of an achoring device?
Thanks Carol Cubellis
First, I will tell you that I am a consultant and speaker for Bard Medical, the manufacturer of Statlock.
The first question to investigate is the amount of bleeding that is being seen within the first 24 hours around the PICC insertion site. This practice originated from the older methods of insertion that used an introducer needle larger than the PICC that was left in the vein. The current insertion methods do not have as much bleeding. So if bleeding is not an issue following PICC insertion, you can stop doing the dressing change at 24 hours. You can also change all CVC dressing change policies to a once per week change interval. I have recently seen a new publication about this, but will have to go through a stack of new stuff to locate it. I will post it on my blog when I find it.
RE the change of all manufactured catheter stabilization devices - you should be following the instructions from the specific manufacturer of the product being used. There are several products available now and they could have different instructions for use. The INS standards do state that a manufactured catheter stabilization device is preferred over other methods of stabilization such as sterile tape or wound closure strips. Published outcomes are far better with these devices. The instructions for Statlock state that this should be changed at least every 7 days and with each dressing change. This device has a coating that allows for easy release of the transparent dressing from the Statlock. Removing the dressing also removes this coating. If the Statlock is not changed with each dressing change, you will not have the benefit of this coating for the second dressing change, making it difficult to separate the dressing from the Statlock. Also, there is no way to adequetely clean the skin without removing these stabilization devices.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
dsnyrn
Yes, there are designs of Statlock that is intended for use with all types of catheters, along with some outcome data published on these catheters. See
1. Frey A, Schears G. Why are we stuck on tape and suture? Journal of Infusion Nursing. 2006;29(1):34-38.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
dsnyrn
Our nurses chose Statlock over other devices they trialed (this was before statlock formally became Bard product).
We change our dressings weekly/prn drsg compromise - new statlock every time.
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
As a PICC nurse in a small hospital with only one nurse on a day we have a different approach that most stated here. We change the initial 24 hour dressing and apply the TegaDerm with CHG. All other dressing are changed by the staff. We have done this for over a year and have not have an increase in line infections. Last, count was one documneted infection in the past 9 months. We are only here 5 days a week and only one nurse. There is no way we can do all dressing. When we had 2 nurses on it could have been possible but not now with budget cuts.
Some days if I have 5 or 6 PICC's to place I have to call the floors to change the initial dressing. It does take contining education and monitoring, but as I said we have NOT had an increase in infections.
Rhonda Wojtas, RN PICC Team
Lowell MA
Rhonda Wojtas, RN,BSN, VA-BC
There are 5 in our Vascular Access Team, with usuallly 2 on shift at a time. We generally have between 30 and 50 central lines. We do not place PICCS, but at this time we round on all central lines and do all dressing changes,place midlines and US guided IVs. We use the Bard Statlock and a CHG gel dressing ( I think it's 3M?). Our Interventional Radiology team places the PICCs. We did a trial of having IR place the CHG dressings at the time of insertion and found that it was very successful. The need for the 24hr dressing change freed up our time so we could assess every CL in house every day.We now have the docs placing the CHG gel dressing on the cordis IV that is placed for open heart. This has increased patient satisfaction,especially on the IJs because we don't have to do an uncomfortable dressing change on an IV that will only be in for another day or 2.
Melanie Arbaugh RN Vascular Access Team
Koootenai Health, CdA, Idaho
Denelle Oliveros RN, CRNI
Nurse Manager
University Option Care
Columbus, Ohio
I have been asked to come up with a reason to NOT go to same-day-of-the-week central line dressing changes. We change at 24 hr post-isertion only if there is blood on the Biopatch present. We then go to weekly changes based on whatever day of the week it is. Our management wants all dressings done on the same day & I have to justify why we don't want that.
Anyone have input? INS doesn't have anything I can find addressing this issue.
Rene Maslow, RN, CRNI
Kaiser Santa Rosa PICC/Procedure RN
ReneMaslow, MSN, VA-BC PICC/Proc RN Kaiser Permanente Santa Rosa, CA