Abstract
Background
Unscheduled dressing changes for central venous lines (CVLs) have been shown to increase the risk of bloodstream infections.
Objective
The objective of this study is to determine if the use of an innovative dressing change kit reduces the rate of unscheduled dressing changes.
Methods
This pre–post interventional study took place at a large, academic, tertiary care center in metro Detroit, Michigan, the United States. We assessed the impact of the interventional dressing change procedure kit on the rate of unscheduled dressing changes for adult patients who underwent placement of a CVL inclusive of a central catheter, peripherally inserted central catheter, or hemodialysis catheter. Data was collected for the pre-intervention cohort through electronic health records (EHRs), while data for the post-intervention cohort were collected by direct observation by trained research staff in combination with EHR data. The primary outcome was the rate of unscheduled dressing changes. Secondary outcomes included rate of unscheduled dressing changes based on admission floor type, etiology of unscheduled dressing changes, and central line-associated bloodstream infections (CLABSIs).
Results
The study included a convenience sample of 1548 CVLs placed between May 2018 and June 2022 with a matched analysis including 488 catheters in each of the pre- and post-intervention groups. The results showed that the unadjusted rate of unscheduled dressing evaluations was significantly reduced from the pre-intervention group (0.21 per day) to the post-intervention group (0.13 per day) (p < .001). The adjusted rate ratio demonstrated the same trend at 1.00 pre- and 0.60 post-intervention (p < .001). Stratifying the analysis based on the highest level of care showed that the intervention was effective in reducing the unadjusted rate of unscheduled dressing evaluations for both the advanced and regular medical floor subgroups pre- to post-intervention; the advanced subgroup had an reduction from 0.22 to 0.15 per day (p = .001), while the regular medical floor subgroup had a reduction from 0.21 to 0.09 per day (p < .001). CLABSIs were similar in both groups (0.6% vs 0.8%; p = 1.00) in pre- and post-intervention groups, respectively.
Discussion
Procedural kits for central line dressing changes are effective in reducing unscheduled dressing changes and may have a role in reducing CLABSI. Further studies assessing the impact of dressing change kits on cost, procedural compliance, and the precise impact on CLABSI are needed.
Keywords: Transparent semipermeable membrane, central line-associated bloodstream infection, central venous catheter, peripherally inserted central catheter, unscheduled dressing change, intensive care unit
Introduction
Current national guidelines recommend changing transparent semipermeable membrane (TSM) dressings every 5 to 7 days and changing the dressing immediately in the event of drainage, site tenderness, other signs of infection, or if the dressing becomes loose and/or dislodges (Gorski et al., 2021). More than two unscheduled dressing changes increase the risk of bloodstream infections by three-fold (Timsit et al., 2012). Evidence suggests dressings are changed much more frequently (Chan et al., 2017; Richardson et al., 2015; Rickard et al., 2016; Rupp et al., 2013). Additionally, inadvertent exposure of the insertion site related to dressing disruption increases the risk of contamination from external pathogens. Decreasing the frequency of unscheduled dressing changes may help decrease the risk of catheter-associated bloodstream infections.
Central line-associated bloodstream infection (CLABSI) remains a serious problem contributing to patient morbidity and mortality. These largely preventable complications have significant costs. Significant interventions focusing on catheter insertion, staff education, hygiene compliance, and appropriate removal of central lines have been helpful in reducing CLABSI rates. Many studies have recently focused on care and maintenance bundles, as most complications occur after line placement (Drews et al., 2017; O’Neil et al., 2016). Specifically, dressing change bundles may help reduce CLABSI rates (Cherifi et al., 2013; Drews et al., 2017; Gorski et al., 2021; O’Neil et al., 2016; Rupp et al., 2013). However, the success of these interventions is based on adherence to recommendations. The most straightforward and intuitive regimen is the most likely to increase compliance.
One possible comprehensive intervention includes a specialized procedure kit for dressing changes. The kit is designed to minimize the cognitive workload on nursing staff with a number of external cues to guide the nurse from one step to the next without relying on memory. The design increases the likelihood of procedural compliance and minimizes omissions. The product intuitively guides the clinician through a series of steps through a sterile dressing change. There are clear illustrations on the kit to prompt the correct next step of the procedure. The goal of this study was to assess if this dressing change kit decreases the rate of unscheduled dressing changes.
Materials and methods
Setting and participants
This study was conducted at an 1100-bed major academic and referral center in Southeastern Michigan. Participants were included if they were hospitalized, age 18 or older, and recently underwent placement of a central venous line (CVL) inclusive of a centrally inserted central catheter (CICC), peripherally inserted central catheter (PICC), or hemodialysis catheter (HD). For the pre-intervention group, patients were excluded if there was incomplete or missing details regarding the dressing assessments. For the post-intervention cohort, research staff were required to conduct the index observation within 24 h of line placement. This study was approved by the hospital’s Institutional Review Board.
Study design
We conducted a pre–post interventional study that assessed the impact of using a specialized procedure kit (ERASE BSI procedure kit by Medline Industries, Northfield, IL) on the rate of unscheduled dressing changes for CICCs, PICCs, or HD catheters. In 2019, all nursing staff with the responsibility of changing central lines received education and training on the key steps involved in the dressing change process along with tutorial on proper use of the kits via institutional clinical nurse education teams as part of a corporate initiative to reduce central line-associated bloodstream infection (CLABSI). Training included a short (30 min) didactic on the dressing change procedure and an introduction (30 min) to the new procedure kit. Figure 1 lists individual product components incorporated into the dressing kit used in this study.
Figure 1.
Components of Dressing Kit. *individual components are customizable and different institutions may have differing needs.
Phase 1: Pre-intervention
We included consecutive patients that received a CVL (CICC, PICC, or HD catheter) from March to December 2018 for the unmatched cohort. During this time period, the interventional procedure kit was unavailable to staff within the hospital. Per institutional guidelines, all dressing assessments and changes are documented at least once daily within the lines, drains, airways (LDA) flowsheets by nursing staff. This data was extracted from the electronic health record (EHR, Epic Systems, Verona, WI). Data abstracted included demographics, admission floor type, catheter type, location, lumens, daily dressing assessments, and blood cultures.
Phase 2: Post-intervention
From January to April 2019, the procedure kits were standardized and disseminated across all units within the hospital. The original goal was to conduct the post-phase in 2020, but this was postponed due to the pandemic. From April 2021 to June 2022, research staff recruited a convenience sample of hospitalized patients with a recently placed CVL. Potential subjects were identified by research staff using an advanced vascular access device list generated from the hospital’s EHR. This document provided research staff with data regarding new and existing line placements. If meeting eligibility criteria, patients were provided an information sheet regarding the purpose of the study with the description of study activities. Patients voluntarily verbally consented to research visual observations of the CVL site. Research staff performed daily assessments on CVL dressing sites in a standard format. This evaluation also included direct observation of the site with a standardized tool, discussion with the nursing staff regarding any dressing changes during the day, and a review of the LDA flowsheets. Data collected was identical to the pre-intervention phase.
Study definitions
Dressing assessments were interpreted using a uniform standard. An assessment was categorized as abnormal if it described bleeding, drainage, excessive moisture, or loosened dressing. All remaining assessments were categorized as normal. Dressing interventions were also interpreted using a uniform standard; for each assessment, the dressing was either changed or unchanged.
For every catheter day, an evaluation consisting of the dressing assessment (normal or abnormal) and dressing intervention (changed or unchanged) was documented. A dressing assessment of normal and dressing intervention of unchanged was considered the institutional standard. If the dressing assessment was normal, but the dressing remained unchanged ≥8 days from the initial catheter insertion or the last dressing change (whichever occurred most recently), the evaluation was designated as “missed scheduled.” If the dressing assessment was normal, and the dressing was changed 7 days after the initial insertion or 7 days from the last dressing change, the evaluation was designated “scheduled change.” However, if the dressing was changed at <7 days or ≥8 days, the evaluation was designated as an “unscheduled change.” If the dressing assessment was abnormal, and the dressing intervention was changed, the evaluation was designated as an “unscheduled change.” If the dressing assessment was abnormal, and the dressing intervention was unchanged, the evaluation was designated as “missed unscheduled.”
Furthermore, research staff only considered one evaluation per catheter day. If the dressing change occurred at the time of catheter removal, then it did not count as a dressing change. Given that there may be more than one evaluation per day, a hierarchy of interventions was established. An unscheduled dressing change superseded any other intervention (Figure 2).
Figure 2.
Table of different dressing evaluations based on dressing assessment and dressing intervention. *from the initial catheter insertion or the last dressing change (whichever occurred most recent).
Data sources/Measurement
Data was collected via combination of direct observation, discussion with nursing staff, and extracted from the LDA flowsheets of the EHR. CLABSI data was calculated based on the National Healthcare Safety Network’s definition of CLABSI. The results were confirmed internally by the Department of Infection Prevention & Epidemiology at Corewell Health.
Outcome measures
The primary outcome was rate of unscheduled dressing changes (both unscheduled change and missed unscheduled change). Secondary endpoints included evaluating the etiology of unscheduled dressing (non-intact or lifting of dressing, bleeding or drainage around catheter insertion site, and other) and evaluating the rate of laboratory-confirmed CLABSI.
Statistical analysis
Pre- and post-intervention placements were compared on demographic and clinical variables. For categorical variables, Chi-square tests or Fisher exact test were used when sparse cells were encountered. For continuous variables, t-tests were used where data were normally distributed and non-parametric methods otherwise.
Because there were some differences between the two periods, matched groups were obtained to analyze the rate of unscheduled dressing changes. Beginning with all placements in the post-intervention period, using estimated propensity scores, matching occurred on age, level of care, catheter type, number of lumens, and location of catheter.
The primary outcome, rate of unscheduled dressing change (per day eligible for dressing change), was analyzed using a negative-binomial model, with an adjustment for patients having multiple placements. Rate ratios were reported for each factor included in the model. Similarly for other outcomes, such as total missed scheduled changes, rate ratios were reported comparing post-intervention to pre-intervention.
Results
A total of 1548 central lines placed between 2018 and 2022 were included in the study (1036 pre- and 512 post-intervention). The average age at the time of catheter placement was 62.9 years for the pre-group and 63.5 years for the post-group. 546/1036 (52.7%) of the pre-group was male, while 248/512 (48.4%) of the post-group was male. The majority of participants in both arms were White or Caucasian (71.6% and 69.1%, pre- and post-, respectively). 58.1% and 56.4% of the pre- and post-arms, respectively, required care in the progressive care unit or intensive care unit during their hospitalization (Table 1).
Table 1.
Demographics and Characteristics of All Enrolled Catheters.
| Variables* | Pre-intervention | Post-intervention | p-Value |
|---|---|---|---|
| (05/2018–12/2018) | (04/2021–06/2022) | ||
| n | 1036 | 512 | |
| Age at placement | |||
| Mean (SD) | 62.9 (16.7) | 63.5 (15.6) | 0.524 |
| Sex | 0.114 | ||
| Female | 490 (47.3%) | 264 (51.6%) | |
| Male | 546 (52.7%) | 248 (48.4%) | |
| Race | |||
| Black or African American | 244 (23.6%) | 131 (25.6%) | 0.470 |
| White or Caucasian | 742 (71.6%) | 354 (69.1%) | |
| Other | 45 (4.3%) | 27 (5.3%) | |
| Missing | 5 (0.5%) | 0 (0.0%) | |
| Highest level of care | 0.619 | ||
| Advanced (ICU or PCU) | 602 (58.1%) | 289 (56.4%) | |
| Regular medical floor | 434 (41.9%) | 220 (43.0%) | |
| Missing | 0 (0.0%) | 3 (0.6%) | |
| Catheter type | <0.001 | ||
| CICC or HD catheter | 419 (40.4%) | 279 (54.5%) | |
| PICC | 617 (59.6%) | 233 (45.5%) | |
| Catheter lumens | <0.001 | ||
| One | 499 (48.2%) | 203 (39.6%) | |
| Two | 391 (37.7%) | 195 (38.1%) | |
| Three | 146 (14.1%) | 114 (22.3%) | |
| Catheter location | <0.001 | ||
| Basilic | 428 (41.3%) | 143 (27.9%) | |
| Brachial | 191 (18.4%) | 86 (16.8%) | |
| Femoral | 79 (7.6%) | 29 (5.7% | |
| Internal jugular | 320 (30.9%) | 230 (44.9%) | |
| Subclavian | 18 (1.7% | 24 (4.7%) | |
| Number of evaluations | |||
| Mean | 6.7 (7.8) | 6.6 (7.9) | 0.315 |
| Median (range) | 4 (1–73) | 3 (1–49) | |
Abbreviations: ICU = intensive care unit; PCU = progressive care unit; CICC = centrally inserted central catheter; HD = hemodialysis; PICC = peripherally inserted central catheter.
*For continuous variables, means (standard deviation, SD) and medians (range) were presented. For categorical variables, frequencies (percentage) were presented.
In the pre-group, the majority of catheters were PICCs (617/1036 [59.6%]), while the remaining were CICCs or HD catheters (419/1036 [40.4%]). In the post-group, however, the majority of catheters were CICCs or HD catheters (279/512 [45.5%]), while the remaining catheters were PICCs (233/512 [45.5%]; p < .001). In terms of the number of catheter lumens, there was a significant difference (p < .001) between the pre-arm (48.2% = one lumen; 37.7% = two lumens; 14.1% = three lumens) and the post-arm (39.6% = one lumen; 38.1% = two lumens; 22.3% = three lumens). The most common location for catheter placement in the pre-arm was the basilic vein (428/1036 [41.3%]), compared to the post-arm, which was the internal jugular vein (230/512 [44.9%]); there was an overall significant difference in location amongst the two arms (p < .001). The average number of eligible catheter evaluations was similar across both groups (6.7 days vs 6.6 days [p = .315]) (Table 1).
The matched analysis consisted of 488 catheters in the pre- and post-intervention groups, for a total of 976 catheters. The average age was 64.2 years for the pre-intervention group and 63.8 years for the post-intervention group (p = .677). Both groups had a similar percentage of females (pre-group = 48.0%; post-group = 52.3%; p = .179). There was no difference in the highest level of care, catheter type, catheter lumens, catheter location, or number of the evaluations amongst the two groups (all p > .05) (Table 2).
Table 2.
Demographics and Characteristics of Catheters in Matched Analysis.
| Variables* | Pre-intervention | Post-intervention | p-Value |
|---|---|---|---|
| (05/2018–12/2018) | (04/2021–06/2022) | ||
| n | 488 | 488 | |
| Age at placement | |||
| Mean (SD) | 64.2 (15.5) | 63.8 (15.5) | 0.677 |
| Sex | 0.179 | ||
| Female | 234 (48.0%) | 255 (52.3%) | |
| Male | 254 (52.0%) | 233 (47.7%) | |
| Race | |||
| Black or African American | 115 (23.6%) | 118 (24.2%) | 0.988 |
| White or Caucasian | 343 (70.3%) | 344 (70.5%) | |
| Other | 26 (5.3%) | 26 (5.3%) | |
| Highest level of care | 0.649 | ||
| Advanced (ICU or PCU) | 292 (59.8%) | 285 (58.4%) | |
| Regular medical floor | 196 (40.2%) | 203 (41.6%) | |
| Catheter type | 0.748 | ||
| CICC or HD catheter | 258 (52.9%) | 263 (53.9%) | |
| PICC | 230 (47.1%) | 225 (46.1%) | |
| Catheter lumens | 0.699 | ||
| One | 208 (42.6%) | 197 (40.4%) | |
| Two | 168 (34.4%) | 180 (36.9%) | |
| Three | 112 (23.0%) | 111 (22.7%) | |
| Catheter location | 0.752 | ||
| Basilic | 148 (30.3%) | 142 (29.1%) | |
| Brachial | 83 (17.0%) | 85 (17.4%) | |
| Femoral | 25 (5.1% | 29 (5.9%) | |
| Internal jugular | 216 (44.3%) | 222 (45.5%) | |
| Subclavian | 16 (3.3%) | 10 (2.0%) | |
| Number of evaluations | |||
| Mean | 6.3 (7.3) | 6.7 (7.3) | 0.892 |
| Median (range) | 4 (1–65) | 4 (1–49) | |
Abbreviations: ICU = intensive care unit; PCU = progressive care unit; CICC = centrally inserted central catheter; HD = hemodialysis; PICC = peripherally inserted central catheter.
*For continuous variables, means (standard deviation, SD) and medians (range) were presented. For categorical variables, frequencies (percentage) were presented.
In the unadjusted analysis, the rate of unscheduled dressing change reduced from 0.21 to 0.13 per day, and the number of days to unscheduled dressing change increased from 4.7 to 7.7 from the pre-intervention to the post-intervention phase (p < .001). The adjusted rate ratio followed similar trend with a reduction from 1.00 to 0.60 from the pre-intervention to post-intervention phase (p < .001). There was no difference in the adjusted rate ratio of unscheduled dressing change for sex, highest level of care, catheter type, or catheter lumens (all p > .05) (Table 3).
Table 3.
Unadjusted and Adjusted Analyses of Unscheduled Dressing Changes.
| N | Total number of unscheduled changes | Total number of eligible days | Rate of unscheduled changes (unadjusted) | Average number of days to unscheduled dressing change | Unscheduled rate ratio | p-Value | ||
|---|---|---|---|---|---|---|---|---|
| Unadjusted | Adjusted | |||||||
| Overall | 976 | 1020 | 6270 | 0.17 | 6.2 | |||
| Age at placement | 1.00 | 1.00 | 0.818 | |||||
| Sex | 0.108 | |||||||
| Female (ref) | 489 | 551 | 3242 | 0.18 | 5.6 | 1.00 | 1.00 | |
| Male | 487 | 469 | 3028 | 0.16 | 6.4 | 0.86 | 0.88 | |
| Highest level of care | 0.772 | |||||||
| Advanced (ICU or PCU) | 577 | 724 | 4036 | 0.19 | 5.9 | 1.30 | 1.03 | |
| Regular medical floor (ref) | 399 | 296 | 2234 | 0.14 | 6.1 | 1.00 | 1.00 | |
| Catheter type | 0.054 | |||||||
| CICC or HD catheter | 521 | 626 | 3135 | 0.2 | 9.6 | 1.55 | 0.39 | |
| PICC (ref) | 455 | 394 | 3135 | 0.13 | 3.8 | 1.00 | 1.00 | |
| Catheter lumens | ||||||||
| One | 405 | 286 | 2233 | 0.13 | 6.4 | 0.66 | 0.94 | 0.665 |
| Two | 348 | 483 | 2792 | 0.18 | 5.7 | 0.91 | 1.05 | 0.608 |
| Three (ref) | 223 | 251 | 1245 | 0.2 | 6.0 | 1.00 | 1.00 | |
| Catheter location | ||||||||
| Basilic | 290 | 241 | 1930 | 0.13 | 12.0 | 0.84 | 0.36 | 0.058 |
| Brachial | 168 | 155 | 1250 | 0.13 | 12.2 | 0.83 | 0.36 | 0.048 |
| Femoral | 54 | 51 | 239 | 0.18 | 3.7 | 1.15 | 1.17 | 0.584 |
| Internal jugular | 438 | 553 | 2720 | 0.21 | 3.3 | 1.34 | 1.33 | 0.201 |
| Subclavian (ref) | 26 | 20 | 131 | 0.16 | 4.4 | 1.00 | 1.00 | |
| Study cohort | <0.001 | |||||||
| Pre-intervention (ref) | 488 | 641 | 3059 | 0.21 | 4.7 | 1.00 | 1.00 | |
| Post-intervention | 488 | 379 | 3211 | 0.13 | 7.7 | 0.59 | 0.60 | |
Abbreviations: ICU = intensive care unit; PCU = progressive care unit; CICC = centrally inserted central catheter; HD = hemodialysis; PICC = peripherally inserted central catheter.
After stratifying the matched analysis based on the highest level of care, the advanced level of care subgroup consisted of 577 total catheters. The unadjusted rate reduced from 0.22 to 0.15 pre- to post-intervention (p = .001). The adjusted rate ratio followed similar trend with reduction from 1.00 to 0.71 pre- to post-intervention (p = .001). The adjusted rate ratio of CICC or HD catheters, compared to PICCs, was 1.55 (p = .004). The regular medical floor subgroup consisted of 399 catheters. The unadjusted rate reduced from 0.21 to 0.09 pre- to post-intervention (p < .001). The adjusted rate ratio followed similar trend with reduction from 1.00 to 0.42 pre- to post-intervention (p < .001) (Supplemental Table 1).
For unscheduled dressing changes, non-intact or lifting dressing was the most common etiology in the pre-intervention group occurring in 49.3% compared to 20.2% in the post-intervention group. Bleeding or drainage was the most common reason for the unscheduled change post-intervention occurring in 55.3% compared to 48.4% as a cause in the pre-intervention group (Supplemental Table 2).
In the entire cohort, the rate of total missed scheduled changes of the post-intervention group compared to the pre-intervention group was 0.87 (p = .362). Furthermore, the rate ratio for total missed unscheduled changes was 1.53 (p = .014), total scheduled changes was 2.24 (p = .003), and total unscheduled changes was 0.40 (p < .001) (Supplemental Table 3).
The overall incidence of CLABSI was 7/976 (0.7%). In the matched analysis, the number of CLABSI events in the pre-intervention cohort was 3/488 (0.6%), while in the post-intervention cohort was 4/488 (0.8%) (p = 1.00) (Table 4).
Table 4.
Incidence of CLABSI for the Pre-intervention and Post-intervention Study Cohorts.
| n | CLABSI | p-Value | ||
|---|---|---|---|---|
| Overall | 976 | 7 (0.7%) | 0.7% | |
| Study cohort | 1.00 | |||
| Pre-intervention | 488 | 3 (0.6%) | 0.6% | |
| Post-intervention | 488 | 4 (0.8%) | 0.8% | |
Abbreviations: CLABSI = central line-associated bloodstream infection.
Limitations
There were some limitations to this study. First, all of the pre-intervention and some of the post-intervention data were obtained from the EHR. It is possible that this data was incomplete or inaccurate at times. Second, post-intervention data, while mostly obtained from direct observation, was obtained from the EHR on occasion. Specifically, data captured on weekends, holidays, or if the patient was away for a procedure was not possible through direct observation. Thus, the same limitation inherent to the pre-intervention arm is present in the post-intervention arm to a lesser degree. Third, the intervention included a standardized kit with specific products based upon deliberate inquiry and consensus of key hospital stakeholders. During the pre-phase, various products were used haphazardly at each step based on the availability or preference of the clinician. It is possible that the reduction in post-intervention phase unscheduled dressing change could partially be attributable to some substandard use of individual supplies in the pre-intervention phase rather than as a result of improving the products and processes as a whole. Fourth, the procedural kit’s impact on aggregate costs of dressing care throughout hospitalization was not assessed and could be an independent driver of use. Additional inquiry is needed to determine the cost effectiveness of the intervention. Finally, as this was a pre/post-intervention analysis, all potential confounding factors likely could not be controlled. It is possible that other interventions may have also impacted compliance with dressing changes or CLABSIs. However, the authors are not aware of other interventions that specifically targeted dressing changes.
Discussion
The study demonstrated the success of an intuitive and simple intervention in reducing unscheduled dressing changes for central venous access catheters. The intervention translated into 40% fewer unscheduled dressing changes during the post-implementation phase. After central line insertion, a major objective is local and systemic infection prevention and focus on the dressing change process is integral to achieving this endpoint (Berriós-Torres et al., 2017). As the dressing serves as a critical protective barrier for the catheter, minimizing contact by reducing unscheduled dressing changes due to bleeding or nonintact dressing is a key strategy to mitigate infection risk (Timsit et al., 2012). In this context, unscheduled dressing changes served as a surrogate endpoint for catheter-associated infection. During the study design phase, we anticipated the volume of CLABSI cases would be low, making it a less appealing and less useful direct primary endpoint. Unsurprisingly, there were only seven CLABSIs and no clear statistically significant difference in CLABSI rates between the pre- and post-intervention periods.
The success of the intervention significantly highlighted the upfront role of the clinician in reducing dressing complications. While not all drainage or dressing integrity is dependent on procedural compliance, this study demonstrated that focusing efforts on the dressing change procedure can improve outcomes. The implication of this study is that the intervention helped enhance knowledge of the dressing change procedure and improve compliance with steps. While a dressing change may seem like a straightforward procedure, at our institution there are 22 detailed steps involved in the procedure. This is consistent with other published tools (Smith et al., 2017). Prior to the intervention, our clinicians operated in a cumbersome system in which nursing staff gathered dressing change supplies in a fragmented approach from a combination of the central stockroom on the floor and decentralized supply carts scattered on the unit. There are numerous possible pitfalls with this approach including opening and discarding unused supplies, using suboptimal products, variation in supply use for each dressing change, missing supplies, and significant wastage of staff time. One study described that collecting the right supplies for a central line dressing change may take up to 25 min (Yaglowski, 2020). This intervention countered all of these potential problems by standardizing and consolidating all necessary procedural supplies (Modern Healthcare, 2015; Value in product and process standardization, nd). The benefits of standardization cannot be overstated as a means to improve effectiveness, efficiency, and lower cost.
The utilization of procedural kits has been shown to improve procedural compliance and improve adherence with aseptic technique with other procedures (Deery et al., 2020). One commonly stocked kit at hospitals, the central line kit, has been shown to have a substantial impact on improving patient safety (Fenik et al., 2013). Higher complexity procedures are not the only procedures that can benefit from a kit (Yaglowski, 2020). When broken down, even simpler procedures have multiple sequential steps that may be difficult to repeat even for seasoned staff without some prompting. Given the many distractions and stocking issues, it was not surprising that even simpler procedures, such as a dressing change, also benefited from a standardized kit. It is notable that while supply consolidation into a procedural kit directly addresses wasted time and missing or nonstandard items, the link to compliance with steps is less clear. Our interventional kit also incorporated a human-centered approach to help reduce medical errors (Pelayo et al., 2021). The product is designed to provide visually appealing external cues for each step to help the clinician comply with essential steps of the procedure. This application of principles of human factors engineering is an effective approach to improving staff compliance and improving infection control (Anderson et al., 2010; Pennathur and Herwaldt, 2017).
Conclusions
Procedural kits for central line dressing changes are effective in reducing unscheduled dressing changes. Despite the lack of meaningful differences in the two-study group, the use of procedural kits may play a role in adherence to aseptic technique for central line dressing changes and positively impact the reduction of CLABSIs. Further studies assessing the impact of dressing change kits on cost, procedural compliance, and the precise impact on CLABSI are needed.
Supplemental Material
Supplemental Material for The use of procedural kits may reduce unscheduled central line dressing changes: A matched pre–post intervention study by Amit Bahl, Nicholas Mielke, Steven Matthew Gibson, and Julie George in Journal of Infection Prevention.
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: AB has research grant support from B. Braun Medical, Becton-Dickinson, Teleflex, Adhezion, Medline Industries, and Access Vascular. AB is a paid consultant for B. Braun Medical, Teleflex, Lineus Medical, and Interad Medical. All other authors have no disclosures.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research was funded via an investigator-initiated research grant by Medline. The funder had no role in the study design, subject enrollment, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all study data in the study and had final responsibility for the decision to submit for publication.
Ethical approval: This study was approved by the Beaumont Health Institutional Review Board.
Supplemental Material: Supplemental material for this article is available online.
ORCID iDs
Amit Bahl https://orcid.org/0000-0001-9495-1293
Nicholas Mielke https://orcid.org/0000-0003-2461-427X
Data Availability Statement
The data that support the findings of this study are available via a data access agreement. Please contact the corresponding author (AB) for this request.
References
- Anderson J, Gosbee LL, Bessesen M, et al. (2010) Using human factors engineering to improve the effectiveness of infection prevention and control. Critical care medicine 38. Critical Care Medicine(8 Suppl). DOI: 10.1097/CCM.0B013E3181E6A058. [DOI] [PubMed] [Google Scholar]
- Berriós-Torres SI, Umscheid CA, Bratzler DW, et al. (2017) Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surgery 152(8): 784–791. DOI: 10.1001/JAMASURG.2017.0904. [DOI] [PubMed] [Google Scholar]
- Chan RJ, Northfield S, Larsen E, et al. (2017) Central venous access device seCurement and dressing effectiveness for peripherally inserted central catheters in adult acute hospital patients (CASCADE): a pilot randomised controlled trial. Trials 18(1). DOI: 10.1186/S13063-017-2207-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cherifi S, Gerard M, Arias S, et al. (2013) A multicenter quasi-experimental study: impact of a central line infection control program using auditing and performance feedback in five Belgian intensive care units. Antimicrobial resistance and infection control 2. Antimicrobial Resistance and Infection Control (1). DOI: 10.1186/2047-2994-2-33. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Deery SE, Cavallaro PM, McWalters ST, et al. (2020) Colorectal surgical site infection prevention kits prior to elective colectomy improve outcomes. Annals of Surgery 271(6): 1110–1115. DOI: 10.1097/SLA.0000000000003194. [DOI] [PubMed] [Google Scholar]
- Drews FA, Bakdash JZ, Gleed JR. (2017) Improving central line maintenance to reduce central line-associated bloodstream infections. American journal of infection control. American Journal of Infection Control 45(11): 1224–1230. DOI: 10.1016/J.AJIC.2017.05.017. [DOI] [PubMed] [Google Scholar]
- Fenik Y, Celebi N, Wagner R, et al. (2013) Prepackaged central line kits reduce procedural mistakes during central line insertion: a randomized controlled prospective trial. BMC medical education. BMC Medical Education 13(1). DOI: 10.1186/1472-6920-13-60. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Gorski LA, Hadaway L, Hagle ME, et al. (2021) Infusion therapy standards of practice, 8th edition. Journal of Infusion nursing 44(1S Suppl 1): S1–S224. DOI: 10.1097/NAN.0000000000000396. [DOI] [PubMed] [Google Scholar]
- Healthcare M. (2015) Standardizing care reduces costs, improves quality. Available at: https://www.modernhealthcare.com/article/20150411/MAGAZINE/304119950/standardizing-care-reduces-costs-improves-quality (accessed 24 December 2022).
- O’Neil C, Ball K, Wood H, et al. (2016) A central line care maintenance bundle for the prevention of central line-associated bloodstream infection in non-intensive care unit settings. Infection control and hospital epidemiology. Infect Control Hosp Epidemiol 37(6): 692–698. DOI: 10.1017/ICE.2016.32. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pelayo S, Marcilly R, Bellandi T. (2021) Human factors engineering for medical devices: European regulation and current issues. International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care 33(Supplement_1): 31–36. DOI: 10.1093/INTQHC/MZAA103. [DOI] [PubMed] [Google Scholar]
- Pennathur PR, Herwaldt LA. (2017) Role of human factors engineering in infection prevention: gaps and opportunities. Current treatment options in infectious diseases. Current Treatment Options in Infectious Diseases 9(2): 230–249. DOI: 10.1007/S40506-017-0123-Y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Richardson A, Melling A, Straughan C, et al. (2015) Central venous catheter dressing durability: an evaluation. Journal of infection prevention. Journal of Infection Prevention 16(6): 256–261. DOI: 10.1177/1757177415594246. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rickard CM, Edwards M, Spooner AJ, et al. (2016) A 4-arm randomized controlled pilot trial of innovative solutions for jugular central venous access device securement in 221 cardiac surgical patients. Journal of Critical Care 36: 35–42. DOI: 10.1016/J.JCRC.2016.06.006. [DOI] [PubMed] [Google Scholar]
- Rupp ME, Cassling K, Faber H, et al. (2013) Hospital-wide assessment of compliance with central venous catheter dressing recommendations. American journal of infection control. American Journal of Infection Control 41(1): 89–91. DOI: 10.1016/J.AJIC.2012.03.011. [DOI] [PubMed] [Google Scholar]
- Smith SF, Duell DJ, Martin BC, et al. (2017) Clinical Nursing Skills: Basic to Advanced Skills. 9th edition9th ed. New York, NY: Pearson. [Google Scholar]
- Timsit JF, Bouadma L, Ruckly S, et al. (2012) Dressing disruption is a major risk factor for catheter-related infections. Critical Care Medicine 40(6): 1707–1714. DOI: 10.1097/CCM.0B013E31824E0D46. [DOI] [PubMed] [Google Scholar]
- Value in Product and Process Standardization (nd) Available at: https://www.beckershospitalreview.com/supply-chain/value-in-product-and-process-standardization.html (accessed 24 December 2022).
- Yaglowski J. (2020) All-inclusive central line dressing kits: a lean approach. Critical Care Nursing Quarterly 43(1): 99–106. DOI: 10.1097/CNQ.0000000000000296. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Material for The use of procedural kits may reduce unscheduled central line dressing changes: A matched pre–post intervention study by Amit Bahl, Nicholas Mielke, Steven Matthew Gibson, and Julie George in Journal of Infection Prevention.
Data Availability Statement
The data that support the findings of this study are available via a data access agreement. Please contact the corresponding author (AB) for this request.