Clinical Guideline No.: CG262
Peripherally Inserted
Central Catheter (PICC)
Dressing Management
Clinical Guideline
Version No.: 1.1
Approval date: 10 January 2020
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Contents
1. Introduction ............................................................................................................................ 3
2. Definitions .............................................................................................................................. 3
3. General .................................................................................................................................. 4
3.1. Requirements ............................................................................................................... 4
3.2. Implementation and monitoring ..................................................................................... 4
4. Safety, quality and risk management ..................................................................................... 5
5. Appendices ............................................................................................................................ 5
6. Reference .............................................................................................................................. 5
6.1. National guidelines ....................................................................................................... 5
6.2. SA Health directives and guidelines .............................................................................. 5
6.3. Additional resources ..................................................................................................... 5
7. Document Ownership & History ............................................................................................. 6
Appendix 1 – PICC dressing procedure .......................................................................................... 7
Appendix 2 – PICC dressing procedure pictogram ........................................................................ 10
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Peripherally Inserted Central Catheter (PICC)
Dressing Management Clinical Guideline
1. Introduction
Peripherally inserted central catheters (PICC) provide direct access to the patient’s bloodstream
and therefore pose a serious risk for infection from microorganisms introduced either at the time of
insertion or while being cared for whilst in situ.
This guideline describes the procedure for performing a dressing change for a peripherally inserted
central catheter (PICC) that is secured with an adhesive securement device.
The guideline will promote a consistent and standardised approach to management of PICC
dressings throughout SA Health facilities.
2. Definitions
In the context of this document:
Adhesive securement device refers to: a device used to secure the placement of a catheter,
typically using a medical adhesive, to attach the device to the skin. Adhesive securement
devices need to be changed routinely every seven days, or sooner if clinically indicated.
Aseptic Technique refers to: a technique that protects patients during invasive clinical
procedures by employing infection control measures that minimise, as far as practically
possible, the presence of pathogenic organisms. While the principles of aseptic technique
remain constant for all procedures, the level of practice will change depending upon a standard
risk assessment.
Chlorhexidine impregnated sponge or dressing means: a dressing product impregnated
with chlorhexidine that is applied to the insertion site to reduce the bacterial load and therefore
reduce the risk of central line associated sepsis. It is available as an impregnated disc
(e.g.Biopatch
TM
) or a gel (Tegaderm CHG
TM
) and requires a weekly change, or sooner if
clinically indicated.
Don means: putting on personal protective equipment (PPE).
Insertion site refers to: the site where the catheter exits from the skin.
Flush refers to: throughout the document denoting a 0.9% sodium chloride flush. Required
before and after all treatment administrations, blood sampling and whenever directed.
Peripherally Inserted Central Catheter (PICC) means: single, double or triple lumen open or
closed (valved) catheter; these are mainly inserted in peripheral veins (brachial, basilic or
cephalic). Some PICCs are pressure injectable which allows administration of CT contrast.
PICCs can remain in situ for up to 12 months.
Pulsatile technique refers to: a ‘stop, start’ technique, where 2mls is injected followed by a
pause, then a further 2mls followed by a pause, repeated until the completion of the
administered fluid. Using a pulsatile technique increases the turbulence within the catheter and
helps to maintain catheter patency.
Securement device refers: for the purpose of this guideline, the term securement device
relates to the type used including adhesive securement device, suture or subcutaneous
securement (e.g. SecureAcath
TM
)
Semi-permeable transparent dressing means: a dressing which has a high moisture vapour
transmission rate (MVTR). These dressings help to reduce the accumulation of moisture under
the dressing; this can help to maintain the integrity of the dressing and reduce bacterial
colonisation.
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3. General
3.1. Requirements
All SA Health services are to align their procedures for the management of PICC dressings with
this document to minimise the risk of infection and ensure a standardised level of care.
PICC dressing management should be performed by, or under direct supervision of, a healthcare
worker who has the relevant knowledge, skills and training.
Strict adherence to hand hygiene and aseptic technique is required for the PICC dressing change.
Appendix A provides detailed information to assist health services with the implementation of this
policy guideline and appendix B provides a pictorial representation of the information.
Key points to consider prior to performing the dressing change:
The photo is an example of a PICC dressing post insertion.
A gauze swab may be placed over the insertion site by the staff
inserting it, to absorb any exudate post insertion.
Note: that if at insertion there has been gauze or product applied to
manage bleeding, the dressing will need to be changed within one day
of insertion.
The dressing should be changed every seven days, or sooner if the
integrity of the dressing is compromised.
Undertake positive patient identification as per SA Health’s Patient
Identification Guideline. Confirm the patient’s identity using the three nationally approved
patient/client identifiers: patient/client full name, date of birth, medical record number.
ASK the patient to state (and where indicated spell) their full name and date of birth.
ALWAYS check this against the patient’s ID band.
NEVER ask the patient ‘are you Mr Jones?’, for example, as the patient may have misheard
and mistakenly agree.
NEVER assume the patient is in the right bed or that the name tag above the bed is correct.
Document the PICC dressing change, clinical assessment of site and external measurement
length.
3.2. Implementation and monitoring
Implementation of this guideline is designed to promote consistency of practice and minimise the
occurrence of healthcare-associated blood stream infections related to intravenous lines, and
consequently reduce the potential for patient harm.
Local Health Networks are responsible for the implementation of the recommendations contained
within this document, including the training and competency assessment of staff who perform
these procedures.
The effectiveness of this guideline will be monitored through:
regular auditing of aseptic technique
regular review of blood stream infection rates by all SA Health public hospitals. Data are
reported monthly as part of the Safety and Quality hospital performance indicator set.
in-depth epidemiological analysis of healthcare associated infection rates, conducted annually
by the SA Health Infection Control Service as part of the statewide healthcare infection
surveillance system.
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4. Safety, quality and risk management
5. Eligibility criteria
Inclusion
This guideline is for use by all SA Health clinical staff working within SA Health services who have
the relevant knowledge, skills, and training in the management of PICCs.
6. Appendices
PICC dressing procedure
PIVV procedure pictogram
7. Reference
7.1. National guidelines
NHMRC (2019) Australian Guidelines for the Prevention and Control of Infection in Healthcare
Queensland Department of Health (2015). Guideline - Peripherally inserted central venous
catheters (PICC) https://www.health.qld.gov.au/__data/assets/pdf_file/0032/444497/icare-picc-
guideline.pdf
7.2. SA Health directives and guidelines
Clinical Communication and Patient Identification Clinical Directive, 2019
7.3. Additional resources
Australian and New Zealand Intensive Care Society (2012) Central Line Insertion and
Maintenance Guideline. Available at https://www.anzics.com.au/clabsi/
Centers of Disease Control and Prevention (2011) Guideline for the Prevention of
Intravascular Catherter Related Infections. Available at
https://www.cdc.gov/infectioncontrol/guidelines/BSI/index.html
EviQ Cancer Treatments Online. (2016). Clinical Procedure - Central Venous Access Device –
Dressing and Needleless Injection Cap Change. Available at https://www.eviq.org.au/clinical-
resources/central-venous-access-devices-cvads/900-central-venous-access-device-dressing-
and-n
Infusion Nurses Society (2016) Infusion Nursing Standards Policies and Procedures, Chapter
4 Site care and Maintenance, CVAD Dressing pp. 116-119
National
Standard 1
Clinical
Governance
National
Standard 2
Partnering with
Consumers
National
Standard 3
Preventing &
Controlling
Healthcare-
Associated
Infection
National
Standard 4
Medication
Safety
National
Standard 5
Comprehensive
Care
National
Standard 6
Communicating
for Safety
National
Standard 7
Blood
Management
National
Standard 8
Recognising &
Responding to
Acute
Deterioration
☒
☐
☒
☐
☐
☐
☐
☐
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8. Document Ownership & History
Version
Who approved New/Revised
Version
Reason for Change
V1.1
Acting Director, Communicable
Disease Control Branch
Move to new template and update
references
V1
SA Policy Committee
Original SA Policy Committee approved
version.
Document developed by:
Infection Control Service, Communicable Disease Control Branch
File / Objective No.:
2017-05179 | A2148185
Next review due
: 10/01/2025
Policy history:
Is this a new policy (V1)?
N
Does this policy amend or update and existing policy?
Y
If so, which version? V1.0
Does this policy replace another policy with a different title?
N
If so, which policy (title)?
ISBN No.: 978-1-76083-226-1
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Appendix 1 – PICC dressing procedure
Equipment required for a routine dressing change
> Non-sterile gloves x 1 pair
> 2% chlorhexidine in 70% alcohol skin preparation
> Sterile gloves x 1 pair
> Needleless connector for each lumen
> Medicated sponge for aseptic hand wash
> Sterile dressing pack
> Sterile hand towels x 1
> Large transparent semi permeable dressing
(e.g.Tegaderm
TM
or Opsite IV 3000
TM
)
> 10ml syringe x 2
> 10mls 0.9% normal saline x 2
> Needleless blunt connector x 2 (if required)
> Adhesive securement device (e.g.StatLock®, GripLok®,
Modulare®)
> Chlorhexidine impregnated sponge or
dressing
> 70% alcohol or 2% chlorhexidine & 70% alcohol
impregnated swabs for disinfection of connectors/bungs
> Plastic backed protector sheet
> Waste paper bag/bin
Note: Assess number of lumens as this will increase some equipment requirements.
1.
Ask the patient to state (and where indicated spell) their full name and date of birth. Always check
this against the patient’s ID band.
Check with the patient and/or the patient medical record written or electronic for any allergy
to skin preparation solution or dressing products.
Explain the procedure to the patient, including that the procedure will require the patient to remain
still for the duration of the procedure, and obtain consent.
Conduct patient assessment of compliance. If patient is disorientated, confused, or non compliant it
is recommended that you seek additional assistance with this procedure.
Perform hand hygiene.
Don personal protective equipment (PPE) as required.
2.
Measure external catheter length (exit point from skin to end of bung/connector)
Compare with insertion measurement. If there is greater than 2cm discrepancy, report to treating
medical team as the PICC line tip location requires investigation. Do not use pending review by
medical team.
Assess insertion site for any visible abnormalities e.g. redness, tenderness, swelling, or exudate.
Gently palpate the insertion site and ask the patient if there is any tenderness or pain. If there are
any abnormal signs or symptoms contact the treating medical team for a collaborative decision
regarding intervention, including potential device removal.
3.
Perform hand hygiene.
Don non-sterile disposable gloves.
Using an aseptic technique open the dressing pack and sterile items.
Place a non-sterile blue plastic backed sheet under the arm to protect clothing and bedding from
skin preparation solution run off.
4.
Gently remove existing dressing, beginning at the device hub. Avoid inadvertently dislodging the
catheter, as it may have adhered to the dressing.
Hold the skin firmly and close to the transparent film edge to prevent the skin from tearing as the
dressing is removed.
Apply adhesive strip if required.
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5.
Remove adhesive stabilisation device according to manufacturer’s directions for use. Remove
gently; 70% alcohol maybe used to assist removal where required.
Take care not to touch the insertion site at any time throughout this procedure.
A subcutaneous stabilisation device is not removed with each dressing change.
If sutures have been used, carefully assess their integrity. If loose, other methods of stabilisation
may be necessary.
Take care not to dislodge or accidently withdraw the unsecured catheter.
Apply adhesive tape/ strip to hold the PICC to skin (if required).
6.
Remove gloves, discard waste.
Perform a one minute aseptic hand wash and dry hands with the sterile hand towels.
7.
Don sterile gloves.
8.
Remove chlorhexidine impregnated sponge (if present) with sterile forceps.
Discard forceps.
Inspect PICC insertion site for swelling, redness and exudate. If there is exudate present, swab the
site for cultures as per local procedure.
9.
Disinfect the insertion site with 2% chlorhexidine in 70% alcohol solution using a gauze swab from
the dressing pack or a commercially pre-prepared sterile 2% chlorhexidine in 70% alcohol swab
stick.
Disinfection should be performed using a circular motion moving in concentric circles from the
insertion site outwards, or basket weave pattern, as per manufacturer’s instructions.
This step should be repeated a total of three times using a new gauze or impregnated sponge for
each application, and each application should be allowed to air dry prior to the next application.
Allow to air dry which may take approximately 30 – 60 seconds.
Note: care should be taken not to dislodge the unsecured catheter
10.
Apply the adhesive stabilisation device as per manufacturer’s instructions.
Use skin preparation if supplied, prior to application of stabilisation device.
Positioning tips:
Take care when selecting the position of the PICC once dressed and secured.
Keep the PICC away from the cubital fossa to prevent bending and fracturing. Bend the patient’s
arm to ensure there will be no kinks or bends in the catheter.
Keep the external length of the PICC away from the insertion site
Do not allow the lumen to overlap the insertion site as this will cause irritation and increase the risk
of infection.
Position the bung on the outer portion of the arm to assist with accessing the bung and to prevent
the PICC from rubbing against the chest wall.
If possible, position the connectors/bungs downwards to prevent the weight of the line interfering
with the seal of the transparent dressing.
11.
Apply appropriately sized chlorhexidine impregnated sponge (if there are no contraindications)
If a Biopatch® is used – the blue side should face up. Ensure 360 degree contact with the skin.
12.
Apply a large semi permeable transparent dressing. The insertion site
should be positioned in the centre of the dressing.
The adhesive securement device must also be completely covered.
Use an additional large semipermeable transparent dressing if required.
Take care not to overlap dressings above insertion site.
Gently press the transparent dressing to ensure firm skin contact.
If adhesive tape/ strip was used – remove this now.
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13.
Prepare new connectors/bungs.
Prime new connectors/bungs with 0.9% normal saline using a 10ml syringe, leaving the syringe
attached.
Disinfect each old connector/bung for 15 seconds with separate 70% alcohol or 2% chlorhexidine in
70% alcohol wipe/swab for each one.
Remove old connectors/bungs.
Note: a non-valved PICC requires clamping of each lumen before removing connectors/bungs;
a valved PICC does not require clamping prior to removal of connectors/bungs
14.
Disinfect/scrub lumen(s) for 15 seconds with 70% alcohol or 2% chlorhexidine in 70% alcohol
impregnated swabs and allow to air dry.
Apply new connectors/bungs, unclamp lumen if required, and flush the PICC with 0.9% sodium
chloride or a suitable flushing solution using pulsatile technique.
Write the date of dressing change on the border of the transparent film dressing.
15.
Cover the PICC dressing with appropriately sized TubigripTM or elasticated viscose tubular
bandage. The bandage should be cut to a reasonable length to cover the entire dressing plus
approximately 4cm (i.e. not too short, as this places undue pressure on the stabilisation device,
leading to patient discomfort). This bandage helps protect the PICC and external lumens and
connectors/bungs.
Remove sterile gloves.
Dispose of sterile gloves and dressing material as per organisation guidelines.
16.
Perform hand hygiene.
17.
Measure external length of catheter and compare with pre-dressing measurement (exit point from
skin to end of bung/connector).
Compare with insertion measurement. If there is greater than 2cm discrepancy, report to treating
medical team as the PICC line tip location requires investigation. Do not use pending review by
medical team.
18.
Perform hand hygiene.
Document the PICC dressing change, clinical assessment of site and external measurement length.
Check patient comfort, offer consumer information sheet: PICC Consumer Information (for adults).
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Appendix 2 – PICC dressing procedure pictogram