Ventricular Assist Device (VAD) Exit Site Care Guidelines

Ventricular Assist Device (VAD) Exit Site Care Guidelines I. STATEMENT OF PURPOSE The Ventricular Assist Device (VAD) Exit Site Care Guidelines are intended to provide standardization and continuity of exit site care for patients post VAD implantation. These guidelines have been developed to improve patient outcomes by promotion of wound healing and prevention of complications (i.e. infections). II. DEFINITIONS Exit Site (also called Driveline Site; wound site ): A permanent wound where a percutaneous lead exits the abdomen. Percutaneous Lead (also called Perc Lead; Driveline): Connects the VAD pump to the controller. III. SUPPLIES YOU WILL NEED: 1. Sterile gloves 2. 2 masks 3. 1 gown 4. 1 hat 5. 3-4x4 gauze 6. 2 to 4 Sterile Drain Sponges (adjust according to amount of drainage) 7. Sterile normal saline (orange lavage capsule) 8. Chlorhexidine solution (Hibiclens) **DO NOT USE any other solution or ointment unless directed by MD or VAD Coordinator 9. Foam (or silk) tape 10. Duoderm 11. Sterile towel IV. PREPARATION OF THE PATIENT Explain procedure to the patient prior to performing. Instruct patient on the placement of the mask, lying still and prevention of contamination of the sterile field. V. PROCEDURE GUIDLINES: The driveline exit site wound requires a minimum daily cleansing and a sterile dressing. It may be required for the driveline care to be done BID to QID basis depending on the amount of driveline drainage. The goal is to keep the driveline site dry and clean. 1. Wash hands and arms thoroughly with warm water and antimicrobial soap. Rinse well and dry completely. **Handwashing is the most effective way to help prevent the spread of organisms. (Hand Hygiene Policy) The antimicrobial soap kills the bacteria or suppresses their growth. Effective hand washing requires at least a 15 second scrub with soap and water; hands that are visibly soiled require a longer scrub. A thorough rinse with warm water washes the organisms and dirt down the sink. The alcohol based hand sanitizer can be used to cleanse prior to the procedure as long as your hands are not visibly soiled. 2. Apply mask, gown. If patient is not on ventilator, apply a mask to the patient also. 3. Unfasten the patient s abdominal binder and leave in place under the patient. 4. Put on clean gloves and remove old dressing. Dispose of old dressing in an appropriate container. 5. Examine the appearance of the driveline site for any signs of infection or unusual drainage. The signs of infection to watch for are redness, swelling, change in drainage amount or color, fever, tenderness or warmth around the insertion site. Normal drainage will be clear (serous) in color and should not be yellow, green or white. If anything appears unusual, call MD or Nurse VAD Coordinator so that the appropriate intervention can be taken. S:\Cardiac Surgery\Center for Circ Support\Patient Discharge Folders\Exit Site Care Guidelines.doc Written 4/98, Revised 2/2000, Revised 3/02, Revised 12/04, Revised 1/05, Revised 1/07, Revised 2/08, Revised 3/10

6. Assess the duoderm to make sure it is intact. It should be changed every 1-2 weeks unless loosening or causing skin irritation. Use four strips of duoderm to outline a square around the driveline exit site where the dressing tape can be applied. Keep duoderm approximately 2 inches away from drive line exit site. 7. Remove clean gloves and dispose of them in the garbage. 8. Wash off tabletop with alcohol or Virex and dry completely. Open sterile towel packaging to use as a barrier between the towel and the table. Partially unfold the sterile towel so that the edges lay within 1 inch of the boarder of the packaging. (Asepsis Technique : MLearning -0 NURS-10054) 9. Place these items on the Sterile Field: *When placing items on a sterile field, you should not touch the contents until you put on your sterile gloves. a. Open 4x4 gauze and place onto sterile field. b. Open Drain sponges and place onto sterile field 10. Apply Chlorhexidine solution to one 4x4 gauze. Replace the lid to chlorhexadine. 11. Apply Normal Saline to one 4x4 gauze. 12. Put on sterile gloves. 13. Cleanse drive-line exit site using 4x4 gauze with chlorhexidine applied. Cleanse in a circular motion, starting at the exit site moving outward and then discard- 4x4 gauze. Remember to make only one circular motion per 4x4 gauze. Clean around the driveline edges without probing into the wound. Remember if you hold the driveline itself as you clean around it, that hand is considered non-sterile. 14. Wipe off chlorhexidine using the 4x4 gauze with normal saline applied using a circular, outward motion. 15. Blot dry gently with dry 4x4 gauze using a circular, outward motion. 16. Apply 2 to 4 drain sponges at driveline site. Cover sponges with tape, applying the tape to the duoderm so no tape is touching the patients skin. Date, time, and initial dressing change on dressing tape. 17. Reapply patient s abdominal binder. 18. Document time of dressing change and site appearance. Instructions for Operating Room: Prior to patient leaving operating room, apply 2 to 4 drain sponges at the driveline site. Cover sponges with foam or silk tape. Date, time and initial dressing on dressing tape. The initial duoderm placement around the driveline exit site will be placed at the first dressing change by the CVICU staff. An abdominal binder will be placed on the patient on admission to the CVICU. VI. RESOURCES: UMHHC ICC Hand Hygiene Policy, http://www.med.umich.edu/i/policies/ice/icm_ptcare/hhygiene.htm. VI. REFERENCES: Infection Control Guidelines for the HeartMate VE Left Ventricular Assist System (LVAS). Thoratec Corporation, 2006. Advanced Practice Guidelines for HeartMate Destination Therapy. Park City Work Group. Thoratec Corporation, 2004. Slaughter et al. Clinical Management of Continuous-flow Left Ventricular Assist Devices in Advanced Heart Failure. The Journal of Heart and Lung Transplantation, Supplement, In Press April 2010. S:\Cardiac Surgery\Center for Circ Support\Patient Discharge Folders\Exit Site Care Guidelines.doc Written 4/98, Revised 2/2000, Revised 3/02, Revised 12/04, Revised 1/05, Revised 1/07, Revised 2/08, Revised 3/10

EXIT SITE CARE: SUPPLIES Patient/Caregiver Instructions You will need many supplies to change the driveline exit site dressing. Prior to being discharged from the hospital, you will be given the name and number of a medical supply company that will provide you the supplies you will need. Dressing supplies can be purchased from any medical supply company or pharmacy. Once home, it will be your responsibility to order your supplies from the medical supply company provided or from a different company (or pharmacy) based on your insurance coverage. Your insurance may specify the preferred company. It is important for you to keep an inventory of your supplies and plan ahead. Please make sure you order your supplies on time and you have the supplies you need for each dressing change. The supplies needed to change the driveline dressing should be kept in one cabinet / area. This will make it easier to gather your supplies for each dressing change and determine when some supplies are getting low. Please notify the VAD Coordinator if there is any problem with your dressing supplies. SUPPLIES you need for your DRIVELINE EXIT SITE DRESSING CHANGE: CLEAN GLOVES Many clean gloves will come in a single box (they are not individually wrapped). They come in 4 sizes (small, medium, large and extra large). These are worn when removing the old dressing from the driveline exit site. STERILE GLOVES Each pair of sterile gloves is individually wrapped (to keep them sterile). They come in many sizes ranging from size 6 (small hand) to size 8 (large hand). Prior to your discharge, the nurse will help you to determine which size you will need. The sterile gloves are worn when you are cleaning the driveline exit site and applying the sterile dressing. MASKS Many masks are in a single box. The masks are not sterile and are used to cover your nose and mouth during the dressing change. The mask prevents germs that we have in our mouth and nose from being breathed onto the driveline exit site. The patient and person changing the dressing should wear a mask. (To put on the mask: loop the elastic ends behind you ears, pinch the top of the mask snug around the bridge of your nose, and pull the bottom of the mask down under your chin.) GOWNS Each gown is individually wrapped and disposable. Several gowns are included in a single box. The person changing the driveline dressing should wear a gown (if it is the patient changing the dressing, the patient does not need to wear a gown). The gown will prevent germs that are on our clothes, or body, from falling onto the driveline exit site and sterile field. (To put on a gown: unfold the gown with minimal touching of the outer portion of the gown. Grasp the upper corners of the gown and continue to unfold it as you hold it out in front of you. Once the gown is unfolded, begin to put your arms in the sleeves, one at a time. Secure the gown at the Velcro points or ties, whichever is provided. Avoid anything touching the gown, keeping it as clean as possible.) S:\Cardiac Surgery\Center for Circ Support\Patient Discharge Folders\Exit Site Care: Supplies.doc 1

HATS Many hats will come in a single box. These are not sterile and are used to cover your hair while changing the driveline exit site dressing. The person changing the dressing should wear a hat. The hat prevents germs and hairs from falling onto the driveline exit site and sterile field. When putting on the hat, please make sure all of your hair is covered. STERILE 4 X 4 GAUZE The gauze will be individually wrapped and are sterile. Many individually wrapped gauze will be included in a box. Please do not open the individual gauze until you are setting up your sterile field (this is described in the dressing change instructions). For each dressing change, you will need (3) 4x4 gauze. The first gauze is used to clean (with chlorhexidine) the exit site, the second gauze is used to rinse (with normal saline) the exit site and the third gauze is used to dry the exit site. STERILE DRAIN SPONGES The drain sponges will be individually wrapped (2 sponges in each package) and are sterile. Please do not open the drain sponges until you are setting up your clean field (this is described in the dressing change instructions). The drain sponge is the dressing we use to cover the driveline exit site. For each dressing change, you will need 2 to 4 drain sponges (depending on how much drainage is coming out of the driveline exit site). CHLORHEXIDINE SOLUTION ( HIBICLENS ) The chlorhexidine solution (also called Hibiclens) comes in a multi-use bottle and you will use a small amount with each dressing change. This solution (applied to a sterile 4 x 4) is used to clean the driveline exit site during the dressing change. Once a multi-use bottle has been opened, it MUST be thrown away after 30 days. A bottle kept longer than 30 days may have bacteria growing in it that could cause an infection at the driveline site. The bottle must be kept sterile at all times. (Do not allow anything to be put into the bottle or touch the opening). The chlorhexidine solution can be purchased from your medical supply company, as well as, any pharmacy or drug store. It does not require a prescription. **DO NOT USE any other solution or ointment unless directed by MD or VAD Coordinator. STERILE NORMAL SALINE The normal saline comes in small plastic (squeezable) tubes and is sterile. It is packaged in small quantities as you will only use a small amount for each dressing change. Please do not save any normal saline that is left (it is a single-use tube and will no longer be sterile for the next dressing change). Normal saline (applied to a sterile 4 x 4) is what you will use to rinse the chlorhexidine solution (Hibiclens) off the driveline exit site. FOAM (or, SILK) TAPE The foam (or, silk) tape is used to secure, or tape, the drain sponges over the driveline exit site at the end of the dressing change. It is a roll of tape and you will cut it to the length needed. S:\Cardiac Surgery\Center for Circ Support\Patient Discharge Folders\Exit Site Care: Supplies.doc 2

DUODERM The duoderm is a solid gel-like dressing. Each sheet of duoderm is individually wrapped and many sheets are included in a single box. The size of the duoderm will be larger than you need and can be cut to the appropriate size (buy one pair of new clean scissors). It is used to protect the patient s skin from being irritated by the tape used to secure the drainage sponge in place. The duoderm is sticky on one side and applied to the skin around the driveline exit site (keep the duoderm approximately 2 inches away from the driveline exit site). You will then tape onto the duoderm instead of the patient s skin. The duoderm is changed every 1 2 weeks OR when it becomes soiled, causes skin irritation, or loosens up. S:\Cardiac Surgery\Center for Circ Support\Patient Discharge Folders\Exit Site Care: Supplies.doc 3

Handwashing Instructions Patient/Caregiver Instructions The first step in changing a dressing is handwashing. This is very important as our hands may have many germs on them from things we touch throughout the day. Some of these germs can cause an infection in the driveline exit site if they come in contact with the driveline exit site when we change the dressing. Following these instructions can reduce the spread of germs from our hands to the driveline exit site. You may use soap and water OR an alcohol-based hand sanitizer. If you can see that your hands are soiled before you start, you must use soap and water (the alcohol-based hand sanitizer will not wash the soil away). Using soap and water: It is important to use an antimicrobial (or, anti-bacterial) soap. These soaps can stop germs from growing, kill them and remove them from your hands. Wet hands with warm water. 1. Apply approximately 1 teaspoon of soap to hands. 2. Rub hands together vigorously for at least 15 seconds (make sure you rub every surface including the areas between your fingers, around your finger nails, and under your nails). 3. Rinse hands in a flowing stream of water. 4. Dry your hands with a paper towel or clean towel. Use the towel to turn off the water. (DO NOT touch the faucet with your clean hands as this may contaminate your hands). Using an alcohol-based hand sanitizer: Alcohol-based hand sanitizers can kill organisms or stop them from growing, but do not remove soil. 1. Apply the product to the palm of your hand. 2. Spread the product across your hands. 3. Rub in briskly until your hands are dry. Be sure to cover all surfaces of your hand and fingers. NOTE: Fingernails should be no longer than ¼ inch in length and artificial nails should be avoided. Germs can hide under the nails. S:\Cardiac Surgery\Center for Circ Support\patient Discharge Folders\Handwashing Instructions.doc

STERILE EXIT SITE CARE Quick Reference Guide for the Patient/Caregiver Procedure for completing the sterile driveline exit site dressing: 1. Gather dressing supplies and set up on clean table: a. Place a clean towel down on the table. b. Open dressings, leaving them in their packages and place on towel. c. Apply small amount of Hibiclens to one package of 4x4 s. d. Apply normal saline to one package of 4x4 s. e. Tear pieces of tape that will be used for the driveline dressing. 2. Wash hands. Put on gown, hat and mask. 3. Unfasten abdominal binder. 4. Put on non-sterile gloves and remove old dressing from driveline. 5. Check and note the color and amount of drainage, the color of skin around driveline, and how well the skin is attached to the driveline. 6. Check to see if Duoderm is still in place. If it is loose, replace. 7. Take off non-sterile gloves and wash hands. 8. Clean surface of table with disinfectant that dressing will be placed on. 9. Set up supplies. 10. Wash hands. Put on sterile gloves. 11. Clean skin around driveline using each 4x4 with Hibiclens soap. 12. Rinse soap off skin around driveline using each 4x4 with normal saline. 13. Dry skin around driveline with dry 4x4 s. 14. Place 2 sterile 4x4 Drain Sponges around driveline, each in opposite directions. 15. Place one sterile 4x4 over the top of the driveline. 16. Tape dressing in place using foam tape. 17. Place binder back on to protect driveline from being pulled. Wash hands. S:\Cardiac Surgery\Center for Circ Support\Patient Discharge Folders\Sterile Exit Site Care.doc 10/07, Revised