Circulatory Device Program Leader Dignity Health/Mercy General Hospital Sacramento, California
Purpose - What was the goal of the study?: To investigate whether applying the same dressing change practices for vascular access device sites to driveline exit sites could improve driveline exit site dressing integrity. Our goal was to increase dressing durability to 7 days, reduce risk of infection, and promote better quality of life for patients.
Background - What was the problem? Why was it important?: Left ventricular assist devices are standard of care for patients with advanced heart failure, serving as bridges to transplant/recovery or destination therapy. >2,000 implants are performed each year and 2-year survival is approaching 73%. However, major bleeding and infection continue to be significant adverse events, with 1 in 6 patients developing device infections within the first year. While technologies differ, today’s devices use an external power source requiring a tunneled subcutaneous driveline. Driveline exit-site care is critical in post-implantation infection control, yet care protocols vary widely and how often to change dressings is not standardized. Recent best practice guidelines cite one study that found no difference in 30-day post-implant infection rates for patients receiving driveline dressing changes daily, 3x per week, or weekly. When comparing driveline exit sites to vascular access device sites within our facility, we noticed parallels in management, infection sources, and goals of care. We wanted to see if applying standard practices for vascular device dressing changes could improve exit site dressing integrity and patient quality of life.
Results - What were the findings?: For this quality improvement project, we divided patients with left ventricular assist devices (N=20) into 2 groups (age range 44-82 yrs; 80% male; average yrs with device, 2.9; range 1-8 yrs). The control group (n=10) used standard dressing kit but extended dressing maintenance from every 3-4 days (2x/wk) to 1x every 7 days. For the intervention group, we added gum mastic liquid adhesive + liquid adhesive remover to the kit and had 2 days of live training with the new items. Patients reported weekly via phone and email including photographs. At 14 weeks, dressing integrity was significantly improved in the intervention group compared to the control group: intact dressings—96% vs 44%; edges lifting—4% vs 48%; detachments—0 vs 8%. Exit site skin condition was comparable, except drainage—0 in intervention group vs ~12% in control group. Overall, 98% of intervention group reached 7-day goal (avg dressing durability=7.01 days) vs 32% of control group (avg=4.9 days). Cost analysis found that fewer dressing changes leads to cost savings of $533.28 per patient annually.
Conclusions - What do the final outcomes mean?: Since no national guidelines for driveline exit site dressing changes exist, we applied standard practices for vascular access device dressing changes to improve driveline exit site dressing integrity. Our findings show the addition of gum mastic liquid adhesive plus liquid adhesive remover with patient-appropriate training significantly improved daily driveline dressing integrity and durability. Patient skin conditions were judged comparable for intact, redness/rash, and blister/skin tears, with no drainage using the intervention. These improvements led to fewer driveline infections, improved patient quality of life (less time changing dressings, ability to maintain active lifestyle), and $533.28 per-patient savings.
