What are defined best practices in the literature to perform a central line dressing change?

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Marschall J, et al.  Strategies to prevent central line-associated bloodstream infections in acute care hospitals.  Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S22-S30.

For nontunneled CVCs in adults

Transparent dressings:  change and disinfect site with chlorhexidine‐based antiseptic every 5‐7 days or more frequently for soiled, loose, or damp dressing

Gauze dressings:  Change every 2 days or more frequently for soiled, loose, or damp dressing

Evidence for this practice came from ≥ 1 properly randomized, controlled trial and evidence considered to be good to support a recommendation for use from the Society for Healthcare Epidemiology of America.

Detailed instructions for changing a dressing are found within the following review article.

Macklin D. Catheter management. Semin Oncol Nurs. 2010;26(2):113-120.

Reviewed and updated 4/11/2014 ldt

Is there evidence about the role of the unit clerk/coordinator in hourly rounding?

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Bottom line:  There is no published evidence documenting role of the unit clerk or coordinator in intentional or hourly rounding.

Details:  Searched Joanna Briggs, CINAHL, PubMed for combinations of these concepts.
hourly, intentional, comfort rounding, rounds, unit clerk, unit coordinator

Reviewed 4/11/2014 ldt

AHRQ-sponsored intervention reduces rates of ventilator-associated pneumonia (VAP) in intensive care units (ICUs)

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Matar, Dany S, et al. “Achieving and sustaining ventilator-associated pneumonia-free time among intensive care units (ICUs): evidence from the Keystone ICU Quality Improvement Collaborative.” Infection control and hospital epidemiology 34.7 (2013):740-743.
This retrospective analysis of the Michigan Keystone intensive care unit (ICU) collaborative showed that a zero rate of VAP could be attained and sustained for a considerable period of time in adult ICUs.

Berenholtz SM, et al. “Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infection control and hospital epidemiology 32.4 (2011):305-314.
Study of an intervention consisting of the Comprehensive Unit-Based Safety Program (CUSP) and a ventilator care bundle of five evidence-based practices from the Centers for Disease Control and Prevention. Reduced rates of VAP by up to 71% at 112 Michigan intensive care units (ICUs).

Reviewed and updated 4/24/2014 ldt

In performing an integumentary assessment, how do definitions of intact and not intact skin apply to documenting intentional breaks in the skin (eg, surgical incisions)?

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Bottom line:  There is no clear documentation in the literature designating intentional breaks in the skin, due to incisions, chest tubes, etc., as specifically not intact skin.

Summary:

CDC Key Terms
http://www.cdc.gov/nhsn/PDFs/HSPmanual/7_HPS_keyTerms.pdf
Non-intact skin is defined as “areas of the skin that have been opened by cuts, abrasions, dermatitis, chapped skin, etc.”

Larson E, et al. Prevalence and correlates of skin damage on the hands of nurses. Heart Lung. 1997 Sep-Oct;26(5):404-412.
This epidemiologic study of skin damage on nurses’ hands describes specifications for non-intact skin. Table II (p. 406) describes completely intact skin as that without abrasions or fissures.

Several nursing blogs include discussions of the ambiguity of how to document skin intactness for patients with surgical incisions.

Reviewed 4/25/2014 ldt

Are occlusive dressings effective for preventing central line infections?

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Webster J, et al. Gauze and tape and transparent polyurethane dressings for central venous catheters. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD003827.
Reviewed six studies; “four compared gauze and tape with transparent polyurethane dressings (total participants – 33) and two compared different transparent polyurethane dressings (total participants = 126).” A four-fold increase in CLABSIs was found with polyurethane dressings. However, because of a risk of bias and wide confidence intervals the “true effect could be as small as 2% or as high as 17-fold.”

McCann M, Moore ZE. Interventions for preventing infectious complications in haemodialysis patients with central venous catheters. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006894.
Includes review of one study (n=58) on use of polyurethane transparent dressings and gauze in hemodialysis patients. There was no statistically significant difference in incidence of central line site infection or central-line associated bacteremia between gauze and polyurethane.

Gillies D, et al. Central venous catheter dressings: a systematic review. J Adv Nurs. 2003 Dec;44(6):623-32.
Searched Cochrane databases, Medline, CINAHL, and CancerLit.  Identified and reviewed 8 studies that evaluate various dressings in the incidence of CVC-related infection and in catheter-related sepsis in hospitalized patients.
RESULTS: Studies included comparison of gauze/tape v. Opsite IV 3000; Opsite v. Opsite IV 3000; Tegaderm v. Opsite IV 3000; Tegaderm v. Opsite.
In the 6 studies with pooled data, odds ratios did not favor either group for incidence of infection. Review was limited in that all studies had small populations.
See Table 4 for summary of meta-analysis.

Hoffman K, et al. Transparent polyurethane film as an intravenous catheter dressing. A meta-analysis of the infection risks. JAMA. 1992 Apr 15;267(15):2072-6
This is a systematic review of 7 studies, but a couple of the studies compared gauze plus a topical antiseptic preparation to occlusive dressing without the topical.

Reviewed and updated 4/24/2014 ldt

What are nurse retention rates at other emergency departments of teaching facilities and non-teaching facilities?

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Bottom line: 4.46% of RN staff nurses left their EDs in 2007. It took an average of 57 days to fill vacancies. Data is from a survey of 700+ emergency departments in the US. Private, not-for-profit, teaching hospitals accounted for 36% of institutions represented and private, not-for-profit, non-teaching hospitals accounted for 22%.

Couselman FL, et al. A study of the workforce in emergency medicine: 2007. Am J Emerg Med. 2009; 27: 691-700
The study was funded by American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, Emergency Medicine Foundation, Emergency Medicine Residents’ Association, ENA, GE Healthcare, and the Society for Academic Emergency Medicine.

Reviewed 4/21/2014 ldt