It was over four years ago on a trip to visit our son that we started a journey to create a way to help protect patients from developing life-threatening blood stream infections. The journey has been long, but today is the day that the US Patent and Trademark office issues our patent for a dressing with moisture indicator. We wanted to take this opportunity to explain why this is so desperately needed and why it works.
The Healthcare Associated Infection Problem
Central line-associated blood stream infections (CLABSI) are a special class of healthcare-associated infections (HAIs) and one that is particularly life threatening, because it can lead to sepsis. Each year in the US, roughly 100,000 people die of HAIs. That’s comparable to a commercial airliner crashing every single day, killing everyone on board. There has been a great deal of energy focused on reducing this problem, but still too many people are admitted to hospitals, have a central line inserted, and get sicker because of CLABSI or some other HAI. Some of those that develop a CLABSI die from this preventable infection.
It was 1:30 AM, and we were driving through western Pennsylvania when Terri exclaimed, because a young patient had developed a CLABSI and by the bacteria and the notes in the chart, she knew what happened. The patient had vomited on their central line’s dressing, and the parents, trying to be helpful, wiped it off. The problem is the moisture and the bacteria that naturally occur in the stomach were now on the dressing. Bacteria need two things to be able to replicate. They need food, and they need mobility. There’s food for bacteria nearly everywhere. The moisture from the stomach and from the washcloth made it easy for the bacteria to get to food and replicate.
Eventually, the bacteria penetrated the dressing, and the IV led them straight to the blood stream, where they could spread out and infect everywhere in the body.
The Dressing’s Role
IVs are used to deliver fluids and medicines to patients. Central lines are inserted into major blood vessels, so that greater volumes, multiple medications, and nutrition can be quickly infused without the complications of peripheral IVs. This is great when you need to be able to diffuse medicine quickly, but it makes them particularly vulnerable to bacteria getting the benefit of the same distribution. The IV dressing is designed to protect the insertion site of the IV from becoming contaminated with bacteria and serving as a direct pathway to the circulatory system.
Dressings, however, must be semipermeable. That is, they need to let the natural moisture emitted by our skin as small amounts of sweat escape to prevent reservoirs of liquid from forming under the dressing. This semipermeable nature means that it’s possible for external contaminants to make it through. The dressing creates a protective barrier but not an absolute one.
As a result, the CDC (and everyone else) says that dressings should be clean, dry, and intact. Cleanliness is an easy visual observation. While the exact standard for what constitutes clean and dirty can be argued, it’s easy to assess the degree of cleanliness by observation. Assessing whether the dressing is intact is slightly more invasive, as it requires that the nurse or provider lift the IV to see whether there are gaps between the dressing and the skin. However, dryness presents a particular challenge.
On the surface, assessing dryness – or wetness – of a dressing should be easy: just touch it. Except nurses and providers – for everyone’s protection – should always wear gloves when touching a patient’s dressing. You can’t tell if something is wet through gloves. It’s possible to assess cold-wetness, because it will feel colder; but because the fluids will be at body temperature, it’s very difficult to determine if a dressing is wet through gloves.
Because dryness is so hard to do, it’s not always done well. In truth, it’s not assessed as often as it should be based on research and healthcare system standards. This is the fundamental problem we solved. We found a way to make dressings tell you visually when moisture is present. The result is assessing dryness is as easy as assessing whether the dressing is clean.
We contributed a chapter to the American Nurses Association book Information Overload. It explains what nurses already know: they’re overloaded. They’re expected to document hundreds of observations per hour, and, for each observation, they may have to make multiple assessments – as is the case for dressings. There’s simply no time to do all that must be done to provide good care for their patients and properly document what is happening.
We recognized that, if we couldn’t make the assessment easy, we’d have no chance of changing behavior and helping nurses change dressings appropriately.
The industry has been moving down a path of using antimicrobials to combat infections. The idea is that, if you use something like chlorhexidine gluconate (CHG) in a dressing, you’ll kill the bacteria and eliminate the need to change the dressing. CHG-based dressings are better than non-CHG-based dressings for those patients that can tolerate it well; however, it creates a secondary set of issues. We have a limited number of chemicals (and metals) that we know to have antimicrobial properties. As a result, we use them frequently when timely cleaning isn’t practical or even possible.
Research indicates that some microbes are becoming resistant to the antimicrobial properties. In short, the antimicrobials are gradually becoming ineffective as the microbes adapt. At some point, we’ll overuse CHG and the other antimicrobials, and they’ll become completely ineffective. We see this already with multi-drug resistant organisms (MDROs) like Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE). We’ve killed the susceptible versions of the bacteria and the resulting bacteria replicates free of competition from its variants.
It’s not a question of if strategies using CHG will become ineffective – it’s a question of when. No one can predict when CHG will stop being sufficiently effective to continue its use, but the day is coming.
The good news is that humans are unstoppable. We’ve done amazing things as a species. This is particularly true when we make it easy to do the right thing. Evolutionary scientists have studied and modeled what has given us the power to be the dominant life form on the planet. Some of this has to do with our capacity to work together, but equally important is our capacity to adapt and to adopt behaviors that help us to protect ourselves and our communities. Caring for patients will never be easy, no matter how much we try to make it so. Having a dressing that signifies the need to be changed due to moisture helps make patient care easier. Making appropriate care easier improves the care we are able to provide and the outcomes for patients everywhere.