O R I G I N A LA R T I C L E

Transparent Film Intravenous Line Dressing

Incorporating a Chlorhexidine Gluconate
Gel Pad: A Clinical Staff Evaluation
Tarja J. Karpanen, PhD, RGN
Department of Clinical Microbiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
Anna L. Casey, PhD
Department of Clinical Microbiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
Ira Das, MD, MBBS, FRCPath
Department of Clinical Microbiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
Tony Whitehouse, MD, MBBS, FRCA, FFICM
Department of Anaesthetics and Intensive Care, University Hospitals Birmingham NHS Foundation Trust,
Birmingham, UK
Peter Nightingale, PhD
Wolfson Computer Laboratory, Institute of Translational Medicine, University Hospitals Birmingham NHS
Foundation Trust, Birmingham, UK
Thomas S. J. Elliott, PhD, DSc, FRCPath
Corporate Division, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

Abstract
Background: Chlorhexidine gluconate (CHG) has been shown to reduce the microbial load at intravascular (IV)
catheter insertion sites and the risk of catheter-related infections. The Centers for Disease Control and Prevention and
the UK National Institute for Health and Care Excellence subsequently recommended CHG-containing IV dressings for
specific clinical indications.
Aim: To evaluate clinical staff perceptions of a standard transparent IV dressing in comparison to a transparent IV
dressing incorporating a 2% (w/w) CHG gel pad when used at the insertion site of short-term central venous catheters
and vascular access catheters for dialysis in adult critical care patients.
Methods: Following a 9-month trial period during which a CHG dressing was introduced to critical care patients at a
university hospital, the staff perception of this dressing in comparison to a standard transparent IV dressing was
evaluated by a questionnaire. The number of dressing changes required and skin condition under the dressing was also
determined in a proportion of patients.
Results: The majority of the clinical staff (70 out of 81 respondents) considered the performance of the IV dressing
containing a CHG gel pad better or much better than the standard dressing, and 77 out of 78 of the respondents
recommended continuing its use. Both types of dressing performed well when applied to the insertion site of IV
catheters in the internal jugular, subclavian, or femoral vein.
Conclusions: Staff satisfaction with the IV dressing incorporating a CHG gel pad was rated good, and the dressing
performed well in a diverse group of critical care patients. Keywords: CHG, critical care, CVC, IV dressing, vascath

Correspondence concerning this article should be addressed to Tom.Elliott@uhb.nhs.uk

http://dx.doi.org/10.1016/j.java.2016.03.008
Copyright © 2016, ASSOCIATION FOR VASCULAR ACCESS. Published by Elsevier Inc. All rights reserved.

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 Background
T he incidence of bloodstream infections associated with the use of
intravascular (IV) catheters is decreasing, partly due to enhanced
adherence to catheter care bundles and
1 months after introduction of the CHG dressing) to reduce any
improved technology. These preventative measures include
education and training of health care personnel who insert and
maintain catheters; use of maximal sterile barrier precautions
during central venous catheter (CVC) insertion; application of
> 0.5% (w/v) chlorhexidine with alcohol for skin antisepsis,
and avoiding routine replacement of CVCs. These recommen-
dations are based on strong clinical evidence; however, there is a
paucity of data to support the selection of type of dressing. 2,3
There is a substantial body of evidence available on the use of
dressings containing chlorhexidine gluconate (CHG) that
demonstrate reduction in the incidence of both catheter-related
infections and catheter site microbial colonization.3-6 The
Centers for Disease Control and Prevention Guidelines for the
Prevention of IV Catheter-Related Infections3 recommend the
use of a CHG-impregnated sponge dressing on short-term
catheters, and antiseptic/antibiotic-impregnated catheters, if in a
particular unit the central line-associated bloodstream infec-tion
rate remains high despite adherence to basic preventative
measures. The CHG-impregnated sponge, which is placed around
the insertion site of IV catheters, requires a secondary,
transparent IV dressing to be applied over it. More recently other
antimicrobial dressings have been developed, including
a transparent IV dressing incorporating 2% (w/w) CHG in an
aqueous gel pad.7-9 The use of the dressing containing CHG gel
has been associated with a reduction in catheter-related sepsis.4
Following a review of the available clinical efficacy data and
economic evidence, the CHG gel dressing has been recently
recommended by the UK National Institute for Health and Care
Excellence to be used on critically ill adults who
require a CVC or arterial catheter in intensive care or high
dependency units.10,11
Aim of the Study
To evaluate clinical staff experience following the imple-
mentation of a transparent IV dressing containing a CHG gel
pad after the use of a standard transparent IV dressing. The
performance of both dressings at 3 different anatomic CVC
insertion sites on 2 types of IV catheters inserted into a
diverse group of critical care patients was also assessed.
Methods
Study Dressings
An adhesive, semipermeable, transparent polyurethane film
dressing incorporating a transparent gel pad containing 2% (w/w)
CHG (3M Tegaderm CHG IV Securement Dressing; 3M Health
Care, St Paul, MN), was implemented for 9 months on the
critical care unit at a university hospital. All patients who had a
short-term CVC or vascular access catheter for dial-ysis inserted
on the critical care unit or in operating theatres had a CHG
dressing applied to the catheter insertion site. Two sizes of the
CHG dressing were utilized: 10 cm 15.5 cm (incor-porating a 7.5
cm 3.0 cm gel pad) and 8.5 cm 11.5 cm (4.0 cm 3.0 cm gel pad).
In comparison, the standard dressing
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used in our hospital, a transparent IV dressing (3M Tegaderm
IV dressing; 3M Health Care), which is an adhesive,
semiperme-able, polyurethane film dressing (8.5 cm 11.5 cm
in size), was studied in 2 phases (7 months before and 6
coincidental temporal effect unrelated to the study dressings.
Staff Training
All staff working on the critical care unit and involved in
the care of patients with a CVC had training and were
competent in the care of CVCs, according to our hospital
policy. The hos-pital guidance on CVC care reflects the UK
epic3 and Saving Lives High Impact Interventions, which are
similar to the Cen-ters for Disease Control and Prevention
guidelines on Preven-tion of Intravascular Catheter-Related
Infections.2,3 These guidelines highlight the main principles
in the prevention of IV catheter-related infections, including
correct hand decon-tamination, strict aseptic technique and
rigorous skin prepara-tion, meticulous catheter and site care,
correct replacement strategy and prompt catheter removal,
and regular catheter site observation (minimum of 8 hourly
observations for inpa-tients). These guidelines also include
indications for dressing change, which recommend that
dressings are changed every 7 days or earlier if they become
soiled, loosened, or fluid appears under the dressing.2,3 To
reiterate the correct CVC site care, posters describing the
correct application and removal of the IV catheter dressings,
indications for dressing change, and regular observation of the
CVC site were also displayed on the unit throughout the study
(during both the standard and CHG dressing study periods).
Before implementation of the CHG dressing, nursing staff
competent in IV catheter care and anesthetists who insert IV
catheters were given training in groups of 1-5. The training
encompassed the correct method for applying and removing the
dressing with emphasis on the differences between the 2 study
dressings. The training also included ensuring that the skin
antiseptic had fully dried before applying the dressing, applying
the dressing without stretching it, positioning the CHG gel pad
over the CVC insertion site, molding the gel pad around the CVC
to ensure maximal skin contact, smooth-ing down the dressing
with a full understanding of the effects of the pressure-sensitive
adhesive in the dressing, and overlap-ping the sections behind the
lumens to close the gap around the CVC lumens. In addition, the
importance of observing the level of the CHG gel pad fluid
saturation was emphasized. This was performed by lightly
pressing the gel pad, and if the resulting pressure mark in the gel
pad did not dissipate or if the gel itself became displaced, the
dressing required replacement. To prevent skin trauma when the
dressing was being removed, the importance of gently folding the
dressing back on itself and slowly peeling the dressing toward
the inser-tion site or in the direction of hair growth was
emphasized. When the dressing incorporating a CHG gel pad
was being removed, the gel pad was moistened with 1-2 drops of
sterile fluid, such as saline, which facilitated removal. The
importance of regular monitoring of the skin condition around
the CVC insertion site and under the dressing, including
inspection of
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the skin for evidence of irritation or erythema and skin macer-
ation, was also highlighted.
Study Approval
Research ethics committee (NRES Committee North West
- Greater Manchester South, No. 11/H1003/4) and hospital
research and development department approvals were
obtained before commencing the study. Informed written
patient con-sent was obtained before inclusion in this study.
hospital), followed by 9 months’ use of the IV dressing incor-
porating a CHG gel pad, a questionnaire was distributed to the
trained nurses on critical care and anesthetists in operating
the-atres who were competent in CVC site care and had
experience of using both types of dressings. The questionnaire
was given directly to eligible staff. Staff members completed
the ques-tionnaire anonymously and sealed boxes were used
for collec-tion of completed forms to ensure anonymity of the
respondents.

Performance of the Dressings Results

The performance of the 2 types of dressings was evaluated
in a portion of the critical care patients. This evaluation
included determining the number of dressing changes and the
phlebitis scores around the catheter insertion site and su-tures
securing the CVC.
Clinical Environment
The IV dressings were evaluated on a critical care unit with
up to 75 critical care beds, at a single university hospital. Pa-
tient groups included surgical (general, cardiac, neurology,
and maxillofacial), medical (general medicine, cardiology,
and hepatology), trauma, burns, and solid organ transplant
(liver, heart, and lung) patients.
User Evaluation
After 12 months’ use of the standard transparent dressing
(which was the standard dressing used throughout the
Performance of the Dressings
Dressing performance was evaluated on 273 patients who
gave their written consent to participate in the study. The
num-ber of dressing changes per patient did not vary
significantly between the 2 types of dressings (P ¼ .96, based
on Mann-Whitney U test) or between CVC when inserted into
the inter-nal jugular, subclavian, or femoral vein sites (P ¼
.75, based on Kruskal-Wallis test) (see the Table). Likewise,
there was no significant difference in the number of dressing
changes per patient when single or multiple CVCs were
inserted into the same anatomic location (P ¼ .24, based on
Kruskal-Wallis test) or when a quad lumen CVC or vascular
access catheter for dialysis was inserted (P ¼ .62, based on
Kruskal-Wallis test) (see the Table).
Similarly, when the number of dressing changes was
adjusted per catheter days there was no significant difference
between the CHG-containing and standard transparent

Table. Performance of the Dressings: The Median Number of Dressing Changes Per
Patient With Interquartile Ranges (IQRs) (N ¼ 273 Patients)
Median number of dressing changes (IQR)
CHG Standard P value Test method

All catheters 1 (1-2) (n ¼ 136) 1 (1-2) (n ¼ 137) .96 Mann-Whitney U test

Location of the catheter insertion site

Internal jugular vein 1 (1-2) (n ¼ 112) 1 (1-2) (n ¼ 119) .75 Kruskal-Wallis test

Subclavian vein 2 (1-2)

(n ¼ 17) 1 (0.75-1.25) (n ¼ 12)
Femoral vein 1 (0.25-2.5) (n ¼ 7) 0.5 (0-1) (n ¼ 6)
Number of catheters at the same insertion site

1 1 (0-2)
(n ¼ 98) 1 (0-2) (n ¼ 98) .24 Kruskal-Wallis test

2 1 (1-2) (n ¼ 38) 1 (1-2) (n ¼ 39)

Type of catheter

Quad/5-lumen central venous 1 (1-2) (n ¼ 123) 1 (1-1) (n ¼ 125) .62 Kruskal-Wallis test
catheter

Vascath* 2 (1-2) (n ¼ 13) 1 (0-2) (n ¼ 12)

*Vascular access catheter for dialysis.
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dressings. The median (interquartile range [IQR]) number of
dressing changes per catheter-days were 0.18 (IQR, 0.11-
0.25) and 0.20 (IQR, 0.08-0.29), respectively (P ¼ .267,
based on Mann-Whitney U test). Furthermore, there was no
signifi-cant difference between the 2 standard dressing study
periods in the number of dressing changes per single CVC
when adjusted per CVC days (period 1: median, 0.20 [IQR, 0-
0.25] and period 2: median, 0.17 [IQR, 0-0.25]) (P ¼ .226, by
Mann-Whitney U test).
There was also no significant difference in the CVC and su-
ture site phlebitis scores between the 2 dressing groups. The
median phlebitis scores for both dressing groups at the CVC
insertion site was 0 (IQR, 0-1; P ¼ .875, based on Mann-
Whitney U test) and at the suture site was 0 (IQR, 0-2; P ¼
.978, based on Mann-Whitney U test).
User Evaluation
In total, 71 nurses who had worked on critical care and 10
anesthetists who had worked in operating theatres for at least
a year responded to the survey. This represented a response
rate of 16.4%. It was also determined that during the study
each nurse cared for more than 200 patients who had a study
dressing applied.
Overall, the staff members were satisfied with the perfor-
mance of the CHG gel dressing, with 86.4% of respondents
rating the overall performance of it as better (35.8%) or much
better (50.6%) than the standard transparent IV dressing (see
the Figure).
Furthermore, 77 out of 78 (98.7%) staff members who
responded recommended continuation of use of the CHG dres-
sing. The supplementary feedback from the users was mostly
supportive of the dressing incorporating a CHG gel pad (9 out of
15 responses), emphasizing their positive feedback
Figure. Critical care nurses’ and anesthetists’ perception of a transparent intravascular line
dressing incorporating a chlorhexidine gluconate gel pad in comparison with a transparent
intravascular line dressing (N ¼ 81). CVC ¼ Central venous catheter.
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136 JAVA Vol 21 No 3
to the structured questions and perceived improved CVC site
securement and protection. Six staff members commented on
the size of the dressing, which 3 of the respondents
considered too large. One health care worker commented that
she would not continue to use the CHG dressing was because
they were too large to apply. These respondents did not state
which size dressing was used. One staff member commented
on dif-ficulties of visualizing the CVC insertion site through
the dres-sing and 3 respondents commented on the stronger
CHG dressing adhesion (a single respondent considered the
adhesive to be too strong). Conversely, another respondent
believed that the CHG dressing poorly secured multiple
lumen catheters. There was no correlation between the health
care workers’ duration of caring for patients with CVCs and
their response to questions (P ¼ .942, based on Spearman’s
correlation r ¼ 0.009).
Discussion
Previous reports suggest that CHG-containing IV dressings
reduce microbial colonization at the IV catheter site and the risk
of catheter-related infection.2,3,10 In addition, cost-efficacy
analysis of the dressings support the use of these anti-microbial
dressings where infection rates remain high following
implementation of the basic preventative measures, or with high-
risk patients.10 Cost-efficacy analysis has indeed suggested that
the use of the CHG gel dressing would save £73 ($105) per
patient compared with the use of standard non-antimicrobial
dressings.10,11 However, lack of clinical staff training and
associated knowledge has been shown to limit the adoption of
new technologies.12 Furthermore, although management of
CVCs and other IV catheters is part of routine patient care in
acute-care settings, postinsertion CVC site care and compliance
with CVC dressing recommendations are
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often inadequate.13 This was illustrated in a recent study
where nearly one-third of CVC had suboptimal dressings in
place, with blood or moisture under the dressing, or the
dressing did not adequately cover the CVC insertion site.13
In this study, staff training, including the use of posters
describing the correct method for using the CVC dressings,
was fully integrated into the implementation of the new CVC
dressing in the clinical environment. The training included
reiteration of the importance of postinsertion CVC site care
and differences between the hospital standard dressing and
the CHG-containing CVC dressing. Appropriate CVC
insertion site care included training to prevent premature
dres-sing detachment and adverse skin reactions. The
importance of allowing a patient’s skin to fully dry following
skin antisepsis was also emphasized in the training because
this not only re-duces the risk of adverse reactions associated
with the applica-tion of dressings onto a wet skin surface,
such as skin maceration and erythema, but also prevents
dressings from detaching prematurely.
Education of staff regarding CVC site care is also of para-
mount importance for the prompt detection of, and response to,
potential adverse events. CHG is a widely used antiseptic and has
been included in body washes, preoperative skin prep-arations,
and incorporated into some medical devices. However, adverse
reactions to CHG have been reported.14-16 In this sur-vey, the
majority of staff rated the patient’s skin condition under the CHG
dressing as the same as, better than, or much better than while
using the standard transparent IV dressing. This was confirmed
by the regular assessment of the skin condition under the
dressing, with no severe adverse reactions being re-ported with
either dressing studied and the phlebitis scores be-ing similar in
both study groups. This suggests that when used appropriately,
the dressing containing a CHG gel pad is safe to use with diverse
critical care patient groups. This has been confirmed in other
studies by our group with the current version of the transparent
dressing incorporating a CHG gel pad.5
Although both study dressings were transparent, semiperme-
able, with a waterproof film, and with the same pressure-
sensitive adhesive, the adherence to skin was rated better with
the dressing incorporating a CHG gel pad than the film-dressing
without CHG. The majority of respondents also considered that
the CHG-containing dressing lasted for up to 7 days, or was
adequate for most patients care plan. These comments may
reflect the additional adherence of the CHG gel pad on the CVC
and skin compared with the transparent film dressing alone. This
also offers an explanation for why 10% of respondents
considered the dressing removal from the skin and catheter was
more difficult with the dressing incorporating a CHG gel pad
compared with the standard transparent film dressing. Although
standard practice for CVC dressing removal was followed, the
removal of the gel pad from the skin and CVC should be
facilitated by the prior application of sterile fluid, such as saline,
between the CHG gel pad and the skin and CVC. This reduces
the adhesiveness of the CHG gel pad and it is seems probable
that this procedure may not have always been followed correctly.
This highlights further the importance of staff training before
implementation
2016
of the dressing into clinical practice, to reiterate the correct
technique for dressing removal, thereby reducing the risk of
skin trauma and CVC dislodgement.
The majority of respondents regarded the ability to visu-
alize the insertion site through the dressing incorporating a
CHG gel pad the same as or better than through the standard
transparent dressing. However, a limited number of staff
members reported the transparency through the dressing
incorporating a CHG gel pad as worse when compared with
the transparent film dressing. The aqueous CHG gel pad
absorbs fluid, which may have affected visualization. This
further highlights the importance of staff education. The
transparent yellow-colored gel pad allows direct obser-vation
of the CVC insertion site without removing the dres-sing;
however, the importance of adequate illumination needs to be
highlighted. This is required to facilitate assessment of the
skin condition at the CVC insertion site adequately. Simi-
larly, a high level of fluid saturation in the gel pad is an indi-
cation for dressing replacement and if this is followed,
visualization of the insertion site should not be impaired. The
gel pad’s ability to absorb fluid compared with a stan-dard
transparent film dressing may also prolong the wear time of
the dressing as fluid accumulation under the film dressing is
reduced. The vapor permeability (ie, breath-ability) of the
dressing also assists in preventing excess fluid accumulation
due to normal perspiration.
Although profiles of both of the study dressings are similar,
there were additional handgrips for application of the dressing
incorporating a CHG gel pad compared with the standard
transparent dressing. This may have been reflected in the staff
responses on speed and simplicity of the dressing application.
It may also indicate the simplicity of the dressing application
where the CHG gel pad is integrated in the dressing, enabling
1-step application.
Conclusions
An IV dressing incorporating a CHG-containing gel pad
was considered by clinical users to have performed well when
implemented on a critical care unit with diverse patient
groups. The value of appropriate levels of training in
achieving this response was emphasized.
Limitations
Product training is an important part of implementing any
new device or practice in a clinical environment. The effect
alone of implementation of the new type of IV dressing in
critical care without training and education of staff was not
studied and therefore no firm conclusions can be made on the
influence of the training alone on the study results. Also, the
training provided was not evaluated by the staff.
The comparator in this study was a transparent IV dressing;
further studies could compare the performance of different types
of CHG dressings, as was recently carried out by another clinical
team.17 Furthermore, this study did not evaluate the
cost implications of adopting the CHG dressing, although this
has been carried out elsewhere.10,11
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 Recommendation for Practice
When accompanied by the appropriate training, a trans-
parent IV dressing incorporating a CHG gel pad can be safely
implemented for the care of a diverse group of critical care
patients.
Acknowledgments
The authors thank the anesthetists and critical care nurses at
University Hospitals Birmingham NHS Foundation Trust for
their continuous support with research. The authors also thank
3M for assisting with the staff training. This work, in part, was
presented at the Third International Conference on Prevention
& Infection Control, Geneva, Switzerland, June 16-19, 2015
(abstract No. IA). The antimicrobial performance of the dress-
ings data were published elsewhere (Am J Infect Control. 2015
Oct 8. pii: S0196-6553(15)00939-6. http://dx.doi.org/10.1016/j
.ajic.2015.08.022).5
Disclosures
This work and presentation of its results were supported by
an educational grant from 3M Health Care, Neuss, Germany.
3M Health Care assisted with the design of the questionnaire,
but did not have involvement in the study design; the data
collection, analysis, and interpretation; in the writing of the
report; or in the decision to submit the article for publication.
Thomas Elliott and Tarja Karpanen have received honoraria to
present at a symposium and attend an international confer-ence
supported by 3M. Thomas Elliott has also received hon-oraria for
attendance at advisory board meetings. The other authors have no
conflicts of interest to disclose.
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