Covalon Technologies Ltd. (COV) Earnings Call Transcript & Summary

Good afternoon, and welcome, everyone. My name is Kate Evely, and I am Senior Director of Clinical Affairs at Covalon Technologies. I want to start by thanking everyone for taking time out of what I'm sure are very busy days to join today's webinar. I think we've got some really great content for you. And I also want to say thank you to everyone for writing into the chat and letting us know where you're joining from and your roles. We're going to try to keep this as engaging as possible. We really encourage you to use that chat to ask questions, share experiences, and we'll also be doing some polling throughout the talk. So today's talk is on addressing MARSI in vascular access, and the role of skin integrity in infection prevention. Without any further delay, I want to get to introducing our speaker. It is my great pleasure to introduce our speaker today, Ms. Sandy Conn. Sandy has over 30 years nursing experience. The first 10 years of Sandy's career were spent in a Level 3 NICU prior to moving to one of the largest and top-ranked institutions in the U.S. Midwest that has over 670 beds and 1.3 million patient encounters a year, where she is currently practicing today. Sandy has a wealth of experience as a bedside nurse, a clinical coach and is currently working in a cardiovascular ICU. With certification in wound care and expertise in vascular access, Sandy is known as a go-to person for wound and skin safety and issues related to medical adhesives. Sandy has spent her career focusing on preventing serious harm in pediatric critical care, and we are fortunate to have her here today to share her expertise with us. I'll pass the -- to Sandy.

Thank you so much, Kate. I really appreciate this and to your company, Covalon for giving me this opportunity and platform to speak about something that I am so passionate about, which is preventing harm to our patients. So today, we're going to focus on defining what MARSI is, the challenges it presents in vascular access. We will identify the patient populations at increased risk for developing MARSI and the impact that it will have on patients and us as clinicians and providers. I will share with you some best practices for prevention of MARSI and the role and the importance of skin integrity for infection prevention and then we'll introduce this innovative technology and then we will finish up with sharing, discussing and interacting with each other and your experiences.

Okay. So just to get warmed up, we're going to do a quick poll. The way the polling will work is, I will activate the poll, and a banner will show up on the bottom of your screen, giving you the opportunity to answer yes or no. All of the responses are anonymous, but I'll be able to see the distribution of responses and share that with you once all of the answers come in. So just bear with me here, when I activate our first poll. Okay, you should be seeing that come up at the bottom of your screen. [Voting]

Thank you, everyone, for answering. 5 seconds left. Okay. There we go. And the distribution of responses there was that 65% of you said, yes, you're actively participating in IV dressing changes and 35%, no. I think regardless, there's going to be some really good useful content that Sandy can share that's going to be helpful, especially for those of you who are at the bedside doing these dressing changes. But also just in relation to medical adhesives in general and skin health. And that really, as we know, has the application in a lot of different areas of practice, not just when you're doing the dressing change. Okay. So we will move on to the next slide, and I'll pass it back to Sandy.

Okay. So we're just going to hit the highlights and the basic, the role of the skin being the largest organ of the body, underappreciated but it serves many functions that we don't think about. It's that outer layer that's on our body, this stratum corneum and it's the first line of defense against infections and protects from mechanical and chemical irritations. And in that skin is where the hair follicles are, the oil and the sweat glands, the nerve endings, which allow us to feel hot, cold, pain. So any damage to the skin compromises the sensory and the protective mechanisms, which leads to increased risk of infection, pain and the delayed healing that we would see.

So thanks, Sandy. At Covalon, we focus on infection prevention with emphasis on compassionate care solutions. And with this slide and with Sandy's help and expertise, we hope to emphasize the critical role that skin health and maintaining skin integrity plays in every infection prevention protocol. But not only the infection prevention protocol, also the impact on patient comfort, quality of life and their overall care experience. I'll pass it back to Sandy now to comment further on this and then move on to a brief discussion on the cost of CLABSIs.

Right. So patient comfort and quality of life. Patients don't like -- they don't even want to be in the hospital or have to go through treatment or having this vascular access device in their body. And any kind of complications that arise from adhesives or doing these dressing changes, it does impact their overall comfort and particularly if they have any kind of irritation or compromise in the quality of life. So we don't want this to be something that is going to be traumatic for our patients. And we're going to go into the cost of CLABSI. So it's the most common hospital-acquired condition in children. There is a lot of focus on CLABSI prevention. The numbers are phenomenal. And when you see a rise in your institutions sometimes you'll often see a rise throughout the country, don't really know the reasons for this, but we constantly are looking at the evidence and putting more and more effort into another way that we can prevent CLABSIs from happening because we know that it leads to increased mortality, morbidity and of -- the length of stay in a hospital. So we do everything we can to get that under control. The cost is approximately $50,000 per infection. If you have a patient that's there long term, and they have 2 infections, that's $100,000. And the hospitals don't recoup that cost. So we need to start talking about this topic. But what is the emotional cost to the patient, the family and us as the clinicians and providers? Because we do all feel something when somebody gets sick and has an infection that maybe we could have prevented. So I'm going to take you on a journey. I'm sure, many of you, clinicians have experienced this. So I'm going to give you an example of things that I've experienced similarly. So if you can just imagine that you're coming on shift for your patient and you have a 2-year-old bone marrow transplant patient who has been inpatient for 12 weeks and 5 weeks ago, received a transplant. And as part of that, a complication developed a mild case of graft-versus-host disease of the skin and she returns to your unit after being in the PICU for sepsis. So if you can imagine, in the PICU constantly being woken up and assessed every 2 hours, the monitors, the beeping, the doctors come and assess you, the nurses do, the respiratory therapists do. You just never get that sleep that you need. So this patient hasn't slept in 4 days and irritable and screams anytime she sees a provider, she's been traumatized when they approach her. And so we'll say that she has a single lumen chest port and a PICC line in her right arm and you're going in, you're doing your assessment at 7:30 in the morning with your vital signs and she's very upset and you're upset, you're trying to keep her quiet because mom is in the back of the room sleeping. But now the mom hasn't slept either since the diagnosis and she wakes up angry because you didn't wake her up first before waking up her child. And so you get that all under control, you come back an hour later to do your site check and you notice the PICC dressing is no longer occlusive. This was not a planned dressing change, and you're wanting to get into the other patient's room that you have and you're trying to get it all done before morning rounds with the physicians coming in. This weighs heavily on us and on the patient and on the family because they weren't expecting it before the 7 days is up. So overall, it's a dreaded situation. And so let's talk about the scope of what this problem of MARSI. It's estimated to impact 1.5 million people annually in the United States. And this statistic came from MARSI as a whole in general. So it can be related to adhesives on the skin in any place. But if we focus in on specifically vascular access patients, 1 in 5 experienced MARSI during the treatment. If you think of your census and how many patients you have and think that 1 in 5 of those will experience a MARSI, makes it pretty prevalent. There's a study that was published in adults, 697 oncology patients with a PICC line reported the prevalence of MARSI at [ 19.7% ]. We know that premature infants and children in the intensive care unit that are chronically ill are all at the highest risk of MARSI. It's -- the studies have shown estimated 16% to 27% of hospitalized neonates will acquire a MARSI due to the routine use of adhesives to secure those medical devices. So I'm talking about the pulse ox probe, the EKG probe, the fully securement device, the surgical dressings, all of those themes contain a medical adhesive. There's a recipe of chemical agents that are put together on the back of a transparent dressing or a monitor probe that we are exposing this patient's skin to. So MARSIs are common in the pediatric populations with some studies reporting a prevalence of up to 55%. Now I want to define what MARSI is. It's medical adhesive-related skin injury, defined as skin damage related to use of medical adhesive products and devices such as tapes, wound dressings, stoma products, very common under stoma products applications, medical patches, wound closures. It doesn't include vascular access, but any of those devices also because those have medical adhesive to secure a dressing on those. And so it's unintentional injury as a result of the care that the patient needs to receive. And we classify these in 4 main categories to be mechanical skin injury, contact dermatitis, folliculitis or a moisture-associated skin damage. And I have some examples here to show you. The first one is the mechanical skin injury, and this is where you see maybe the skin stripping or the skin tears upon removal of that dressing. As far as tension injuries go, I'd like to explain this because you have the dermal layer of the skin and -- the dermal layer of the skin and the epithelial layer of the skin. And when you typically look at cross-sections of the skin, it's demonstrated like this that you have fingers, projection of the dermal layer up into the epidermis and down. And these are called rete pegs, and that's what attaches those 2 layers together. Oftentimes, some clinicians not so much now as it used to, would take that transparent dressing and stretch it and then put it down on the skin because they wanted to make sure the device didn't move. Well, when you release that dressing, it will go back to its normal size and shape. And what happens to the skin underneath it now is the skin cools, and it loosens those rete pegs and it pulls that epithelial layer away from the dermal layer and you have sebum and other moisture components that are now going to probably form a blister. And so those are tension injuries. The second example is of dermatitis. We have contact dermatitis and allergic dermatitis. And it usually exhibits itself with inflammation, redness, itching, usually directly related to the chemical irritant on the skin. It can be hard to determine whether it's allergic or just a contact dermatitis. Sometimes you might need to involve your dermatology department to help you with that. But typically, a contact dermatitis, you will see more a mild erythema and itching -- complaint of itching or with a child tugging and pulling out the dressing trying to get it off. Allergic dermatitis is going to be those deep red vesicles that look really angry in -- usually in a concentrated area. Folliculitis is important to recognize because as we age, we grow more hair. And so we'll take, for example, a teenage or a male adult. It's important to clip that hair before you apply any kind of dressing because when you go to remove that dressing for your next dressing change, the -- however much hair is in contact with that adhesive dressing is going to come in contact with it when you pull that adhesive. It can pull that hair follicle or hair shaft out of the follicle and that follicle then is going to fill up with sebum and fill that void. And so you're cleaning your -- with antimicrobial agent, and then you're going to put this occlusive dressing back on it. But now you have just entrapped fluid that comes from the skin that can accumulate bacteria in there, usually ends up being a staph infection. So it's very important if you see this prickly looking kind of rash on a patient with hair that you actually consider that it might be folliculitis, and have a provider come look at it and see if treatment needs to happen. And then the last one is maceration, which is inflammation or erosion of the skin for prolonged exposure. Now this is an example of a woman's finger with probably a Band-Aid that was on there and doing dishes for an hour. But what happens when you're in a bathtub, the longer you stay in there, the skin cells will absorb as much moisture as it possibly can. And when that happens, it swells up. And so you get thickening of the skin, but it also makes the cells more fragile because they've expanded and they've gotten thinner. So maceration can also cause skin injury and compromise that integrity. When we look at our patient population at increased risk, so anybody with frequent dressing changes. When you put that dressing on, it's intended to stay on there for 7 days. But if it's any shorter than 7 days, you still have a lot of that acrylic adhesives exposed to the skin. And then if you pull it off sooner, you can be taking some of the skin cells that weren't ready to naturally shed off at that time. Neonates and pediatrics, the gerontology patients. Age-related skin fragility as we get older, we lose elasticity, we lose collagen in the skin. So they are more at risk and patients with diagnosis of malnutrition and dehydration. We'll talk more about that later. Medications, the corticosteroids, radiation and then any patients with dermal pathology such as eczema or psoriasis. And so with our next slide, we are going to look at intrinsic versus extrinsic. So intrinsic factors would be the patient's age, being aware if they're a premature infant, a young infant or whether you have an older patient who has that fragile skin. Race and ethnicity, it's very important now with recognizing the risk associated with that. When you compare white skin to dark-pigmented skin, black skin. We know that in black-skin patients that they have more transepidermal water loss and they are more susceptible to dry skin. So they really like to moisturize their skin and use emollients after their bath and shower. So there's a lot of variations. And the other thing is assessing color. It's easy to see redness in a white-pigmented patient versus in a dark-pigmented patient. You don't see red. What you actually see is a darker pigmentation. So I think we need more attention to how we document because documentation now is like click here, click there on these descriptive words. And oftentimes, people don't have darker pigmentation as a descriptor when they're describing the skin. Dermatological conditions, such as epidermolysis bullosa, which are those patients that have problems with that connection between the epithelial dermal layer and they're very prone to blisters. Graft-versus-host disease. The integumentary is very compromised and then dermatitis that falls underneath there, eczema, psoriasis. Most people have a home regimen if they have any kind of dermatitis that they keep that under control. However, what we know can exacerbate that condition is stress. So a patient going into the hospital and getting sick can have an exacerbation of their dermatitis. Underlying medical conditions. So diabetes mellitus affects healing, infection, any kind of renal insufficiency, immunosuppression, venous insufficiency and hypertension. So really important for that oxygen to get to the skin cells so that they can heal and not be compromised. And then nutritional deficiencies. Here I think about the patient in the ICU maybe who had a bowel perforation or a neonate who has necrotizing endocolitis. We're not going to feed that gut. So they're not going to get the optimal nutrition. We'll give them total parenteral nutrition and they'll get that vascularly. But that's not optimal for wound and skin healing. And then dehydration, where I see that happening in my world of cardiac is a patient has hypotension. So we're going to use [indiscernible] suppressants and then give fluid and the more fluid you give then the more swelling and edema you have, which can put the skin at risk. But then when you go to diurese them, you then can cause dehydration of the skin because you've pulled all that moisture out back into the vascular system. So you really need to know where they are nutritionally. And then the extrinsic factors, if they're subjected to radiation therapy or phototherapy, prolonged exposure to moisture, I talked about leaving -- noting that if there's moisture underneath the dressing and you don't take it off because it's just a little bit of moisture, but it's still occlusive. And then the mechanical component, improper application. I talked about stretching that or removing the adhesive dressing. The companies that make some of these have specific instructions how to remove their dressings. It's not like peeling it back. It's slow and low and pulling it towards you so that it gently lifts off the skin, and it's less traumatic. Medications that we know, which affect the skin cell structure are steroids, anti-inflammatories or chemotherapy agents and then drying of the skin due to cleansers and excessive bathing. So what do we do in the hospital because you're at increased risk of surgical site infection. In CLABSIs we give you baths every day or neonates might be 3 times a week, depending on your practice. And so that excessive bathing and exposure to moisture and then we put chlorhexidine wipes on top of that in our infants and our adults. And so we're exposing them a lot. Even the dryness in the air, I was thinking about this, our babies often -- not our premature infants, but babies are on radiant warmers, right? And because if they're in the ICU, we have to have full visualization, and we have the warmer above them, but that's all dry air. They're not in a onesie sleeper, wrapped in a blanket with that warmth and everything. So my point here is the awareness of these risk factors is the first step to prevention, thinking about, okay, what intrinsic factors makes my patient risk here? And then what are we doing to them that puts them at further risk. And if you are aware of these potential risk factors, that's the first step in the prevention is awareness. Common causes of MARSI in vascular access would be the improper selection of product. We talked about the adhesive dressings, the securement device, the amount of adhesive. I don't know with some of your institutions -- maybe put in the chat. Do you have different manufacturers or choices of adhesive dressings that you can alternate or is it 1 dressing for all patients because that's your standard of care? So do you have a variety of selection of products? Limited product availability for high-risk patients. And so today, we're going to talk about the silicone transparent dressing. Is it available in your institution? We're going to be talking more about that later. But I think availability, we really need to start bringing this to the forefront of the conversations with our CLABSI collaborative and the leaders at the table if you don't have that product available. Lack of training. It would be your nurses or clinicians that change the dressing. I know with older nurses, like, myself, who have handled central lines for over 30 years. I remember back just like 10 years ago, it just wasn't complicated, doing a dressing change. It's just -- but now it feels like there's so many steps and things that we have to be aware of to that dressing change to make sure it's done exactly the way we want. And so some people just do it the same way they've been doing it, even though your institution may have changed the standard of how they want the dressing changes to go. The other causes would be high concentration of active ingredients. We're also going to talk about the varying concentrations among different dressings that have chlorhexidine in them. Another cause, not allowing enough time for the cleansing agent or barriers to dry thoroughly. I see this a lot. This is not uncommon. People get in a hurry, and they've cleansed with chlorhexidine, and they don't let it dry and there's a little puddle underneath there. And that's when you'll see like a distinct area under an adhesive dressing and maybe it's circular or something, you're like, "yes that's probably where it didn't dry or anything." And then again, we could talk back to the occlusive dressing that's on for too long and not getting that dressing off when it needs to be removed. So most of these complications can be avoided with that knowledge that we're giving you today and recognizing the risk factors. So I ask you, do you just grab the dressing change kit, the standard kit? Or do you ask yourself some more of these questions before moving forward with your addressing change? The impact that MARSI has on our patients and the providers. So we talked about that patient example that I gave you, the anxiety, not only the patient, but the family has experienced. Anticipatory pain, they don't like it every time they get their dressing changed. They don't like it when you take the adhesive off. I often let older children be a part of that. And like, do you want to loosen up the edges for me? That way they can kind of control that pain and discomfort, but it can also lead to heightened pain experience. Maybe some patients like this patient that I gave you earlier that dreaded change might need some sedation and you're going to have to get that from the doctor. And if you're trying to wean a patient off of sedation, you're exposing them to a medication again. And so it all takes an emotional psychological trauma with a dressing change on the patient and the family around you. Now think about ourselves. With that patient, I would have a lot of angst. I really would. I'd be like, "man my morning didn't go the way I wanted it to, that mom is mad at me. I don't want her to be mad at me because then the child's going to sense that." It's just this evolving situation, it's very distressing. It's time consuming. I wasn't planning on a dressing change. And I've got to ask other people to help me. And this can lead to unpleasant interactions with patient and family. Although we know it's not our fault that the dressing became unocclusive. Sometimes parents have displaced anger right? Because it's a situation they can't control. And so then they become angry with us. We don't take it personally, but it still causes distress on us.

Thanks, Sandy. That brings us to our next polling activity, everyone. So this image you're looking at, this is a patient who had a port inserted. The site was covered with the standard transparent film dressing with acrylic adhesive containing no antimicrobials. Redness was noted through the dressing prior to it being removed, and it was reported that the patient was itching the area while the dressing was in place. With this limited information, how would you classify this case of MARSI? I'm going to start the poll here right now and we'll do 30 seconds starting now. [Voting]

That's half the time passed, 15 more seconds. Okay. So the results are: We had 36% of you say mechanical injury, 53% on contact dermatitis and 8% other. And my understanding, confirmed with Sandy, of course, is that one of the key facts here is that the redness was present prior to removal of the dressing. But I will pass it back to Sandy to go over that and talk about how she would assess this.

Right. This is when I love, okay? So I am an investigator, okay? So what are the causes? So I have to ask some questions. I have to look at the patient, they have ever had any reactions like this before, what treatments are they going through? Talk with the family, talk with the nurse. Was the redness there before you took the dressing off? And so they're saying, yes. So that, for me, kind of rules out a mechanical injury. Again, I'm going to look and see if this redness dissipates over time. But what stands out to me is the redness is across the whole chest. And I can see clear delineation of kind of a line which has demarcations where the dressing was. And so that tells me that it is dermatitis because it's in full contact of where the acrylic dressing was and so that would lead me to thinking that it's a contact dermatitis. And so the situation for this patient, we know, it was an 18-month old experience in skin breakdown irritation at the access site of the port and the chest wall. It was covered with that transparent dressing with the acrylic adhesive, which resulted in irritant contact dermatitis, presenting itself with erythema and causing itchiness. So moving forward, they decided to trial a silicone dressing for this patient and the patient tolerated it very well and the underlying skin site improved over the course of 7 days. So this is exciting. So looking at this before and after picture, not only do you see the redness that's gone and the swelling. But looking at that incision, so in the before picture, you see bright redness, maybe not great approximation on the superior aspect of that incision. And when you look at the after picture, that wound is well approximated. It's perfect healing that you would expect for a surgical site incision and really minimal scarring -- probably, in the future, have very minimal scarring. So I really like that they used the silicone dressing on this, and I'm sure it was very -- much more comfortable for the patient, wearing it and upon removal.

Okay. So that brings us to our third poll. And I mean, having just walked through that case with Sandy, we thought a good question to ask and survey would be, does your facility have a protocol for MARSI at vascular access sites? Is there something you can look to that go through a sequence of steps that would help you figure out what the right pathway for that patient is, what the right dressing for that patient is? Or is this something that you kind of are assessing on your own and working through? Okay, I will start our poll. And again, we will have 30 seconds to answer. [Voting]

Okay. 10 seconds to go. It looks like we're seeing the majority are saying no. Okay. About 75% of you said, no, and the remaining 25%, yes. I will pass back to Sandy to comment on that and go over some of these probably helpful questions that can be used when assessing different sites.

Right? So we will walk through this one together. This is an elderly woman, in this reaction, you want to ask yourself, was this reaction present during the wearing and before the removal or following the removal. And when I'm assessing this, I have to decide was it because of the adhesive material or cleansing agent, is it moisture associated. But I do want to point out, so the red circle, I would ask the nurse and I'm going to assume here that there was only an antimicrobial disk at the insertion site, a chlorhexidine disk at the insertion site. Now I have to think if -- is that a sensitivity to that chemical agent or could this be a pressure injury because I have very clear defined lines of where maybe that disk was sitting. And if I had somebody that took that dressing and stretched it and put it on there, that disk, it's got some height and only place it can go is into the skin because the skin is going to be forgiving, not the dressing. And so I have to look at that and think, I'm not sure if it's pressure, and I'm not sure if it's an irritant from the disk there. Does the patient have any known sensitivities to acrylic or chlorhexidine or ever experienced anything like this. And so I would ask all those questions. But moving forward, I would opt for a silicone dressing. I would not be hesitant to put a dressing with chlorhexidine and silver impregnated in that because I really don't think it is related to the chlorhexidine. I think that really is more of a pressure injury, but I would go ahead and give the protection and do the chlorhexidine and silver, but with a silicone dressing and remove that component of the acrylic exposure and that way it's going to give me full transparency to monitor that site every day to see if it's improving and making sure that it's not getting worse, that site -- insertion site is not obscured by any other product. And so our take-home message here is prevention of MARSI should be the standard of care in every patient population. I personally was introduced to this product, I'm going to guess, 7, 8 years ago. And as soon as I saw it, I loved it. But how do you get buy-in from everybody, right? I personally try everything myself. Don't be afraid to ask for samples. And so I take every dressing that I have at my disposal at my institution, and I put it on my skin. I sometimes put drops of moisture underneath it and put dressings on. And then I remove it because I want to know what the patient is experiencing. I want to know firsthand, so I can speak to the experience and not just the experience of what I've seen in other patients, but for myself. I think that gives a little more credibility. And so if you're able to do that, when I can swap dressing that is on other people that have -- you have the opportunity to influence and to get buy-in from. That's what you need to do because then they will recognize that and be like, "Oh, yes, that comes off much nicer. Yes, I do like that I don't have to use an acrylic dressing along with CHG disk at the site, using more products than an all in one. So I like it. It's less steps to the dressing application process." And so let's talk about the best practices moving forward for that prevention. Being aware of your patient history, the allergies and any history of compromised skin integrity, letting the preps and cleansers dry completely before you apply the dressing. If you suspect an allergy or contact dermatitis, you can always do a patch test or get dermatology involved to help you with that. So you know what the sensitivities are. The application and the removal of that dressing. Don't stretch it and low and slow when you're removing those other dressings. Assess the sites daily using a transparent dressing that gives you full visibility is going to be an advantage to you and consider using an atraumatic adhesive dressing. So what's the different? Like this atraumatic silicone versus the acrylic adhesive, I'm going to jump right to this picture on the right-hand side to tell you about acrylic adhesive and what I've learned from some of my reps that sell different dressings. So your transparent dressing with the adhesive is a sheet of plastic, which is your transparent dressing. And then there has to be a layer of acrylic adhesive that gets applied to that. That can be done in different ways. It's either just going to be 1 sheet of acrylic adhesive or now they're starting to do technology where they drop it in droplets versus -- they think that it will aid in the removal of the dressing. But you see here the pink and red skin cells, right? So the beige ones are your healthy skin cells, the ones that are ready to not truly shed over time. And you've pulled off more than the mature cells that were ready to shed, you have some immature skin cells. And so this is where the redness comes in and the irritation that you see as opposed to a soft silicone being a safer level of adhesion. When we talk about adhesion, it's just bringing 2 layers together to stick together. It doesn't necessarily mean that you have to have a chemical agent to make that happen. And so silicone is -- it's nontoxic, and it minimizes the likelihood of the sensitivities. And the way that happens is it's like attack. Silicone, it's pliable. It's soft. And with our skin, you have stacks and layers of skin and the skin cells are of varying heights. And when you apply that silicone, you attach it to like the hills and you think of hills in a valley. So it's going to -- that first adherence is going to go to the top layer of that skin. But it will eventually conform to the skin and fall into the valleys and you get more adhesion as the dressing warms up to the body temperature. And so its traction, it has traction from the higher cells, the lower cells and it doesn't move, but it doesn't have that acrylic adhesive that when you're going to pull it off, it's a soft silicone that you're just going to peel back. And if it takes any skin cells, it's going to be the skin cells that are already mature and would normally sluff off anyways. Here, we have an example of chlorhexidine, and we're going to talk about the concentrations of the chlorhexidine, and the picture in the upper right-hand corner is going to be a PICC in the left femoral of a neonate. And the dressing, I understand that was used on this was a transparent silicone dressing with a gel chlorhexidine patch attached to it. And the dressing was on for 7 days. And when they took the dressing off, this is what they saw. Again, this is what I like figuring out what the cause is, right? So is it chlorhexidine? Is it the adhesive? Well, what I know -- would suspect, if I were there, was that this gel patch. So the gel can turn to moisture, if you think about maybe a baby under a radiant warmer, it's going to get more gelatinous, but it had chlorhexidine, and maybe it had a high concentration of chlorhexidine in it. So when they removed this dressing, they thought this was purulent and when we describe wounds, oftentimes, if you see anything yellow, beige, tan, you think it's puss, you think it's purulent, you think it's infectious as they did, and they cultured it and sent it off to the laboratory for every type of culture they could, bacterial, viral, fungal, and it came back negative. But it's really important to know the cause of it. So this patient received antibiotics. And when we have this responsibility for antibiotic stewardship and so we expose the patient to antibiotics and it didn't necessarily needed it. It wasn't an infection. It was an irritation from the chlorhexidine impregnated into -- I mean the gel patch that skin was exposed to. And so if you would use a transparent dressing on there, you would see much improvement. Down at the bottom here, we have a right femoral access line. And this is interesting because I thought immediately, it looks like maybe where a chlorhexidine disk was, but it wasn't at the insertion site. I don't know the article doesn't specifically say that it was related to any kind of patch or anything, but it's in the crease of the groin. And I want to talk about the color of these 2 wounds. They're not purulent, they're not puss. It's actually fibrin and fibrin is healthy in a wound bed because when it gets down to the dermal layer and it wants to bleed, fibrin is produced to help it clot and fibrin is yellow. So this isn't sluff and it's not infectious material, it's actually fibrin. And with this dressing, I don't really think it's probably the acrylic adhesive. Again, I think it's exposure to chlorhexidine. And if that was a puddle that sat in that crease might be what that is. And you could perform a patch test in other areas of the patient to decide what their irritant is. Yes, go ahead.

Thanks, Sandy. So I'm just going to add on and talk a little bit very briefly of the chart that's at the bottom of the screen. At Covalon, we're very focused on atraumatic adhesives, specifically silicone. But we understand, of course, that chlorhexidine is an invaluable tool, and it is so important when it comes to infection prevention at these vascular access sites. The one thing I think that is important to highlight is, and as Sandy has that not all chlorhexidine dressings are constructed equally, using the same materials or with the same amount of chlorhexidine. And so just based on manufacturer information, we pulled together this chart. And what you have here is the total amount of chlorhexidine in 3 different dressings, which are available and widely used in the market, dressing 1, a silicone dressing with antimicrobials; dressing 2, an acrylic dressing with the CHG gel pad, which as Sandy referenced in relation to the cases shown on the right, the image is there; and dressing 3, which isn't necessarily a dressing but a polyurethane foam disk, which contains chlorhexidine. And if you look at these overall content -- chlorhexidine content in milligrams, you can really see the difference. And I think it makes it clear that why if 1 chlorhexidine dressing might not be a good option for a patient. It might not mean that all chlorhexidine-based dressings are not suitable. So I will move us on -- unless, is there anything you'd like to add there, Sandy?

No. I mean this was eye-opening for me. I think we just think chlorhexidine is chlorhexidine, but don't realize the doses that it actually comes in.

Right. Okay. I'm going to move us on to our final poll. And again, staying focused on the dressings, are different IV dressing options available for you when treating patients with sensitive skin or an existing case of MARSI? And I will just get our poll pulled up here. And you should see that now at the bottom of your screen. [Voting]

Okay. Last couple of seconds. Okay, great. And the answers come in at 80% of you said, yes, they are available. And the remaining 20%, no. Okay, so we are getting towards the end of our presentation here with just 8 minutes left in the hour. And I just I just wanted to wrap things up by offering a little bit of information about a few silicone dressings, which Covalon offers. In our vascular access line of products, we offer both an antimicrobial silicone dressing and a non-antimicrobial silicone dressing. The antimicrobial silicone dressing is called IV Clear, and it contains both chlorhexidine and silver. What makes the distribution of the -- and the use of the antimicrobials quite unique is that they're homogeneously embedded in the entire surface area of the dressing. So rather than being concentrated into 1 small area you have coverage throughout and that achieves the same degree of efficacy when it comes to log reduction. It also means that we can keep it transparent throughout or across the entire surface area of the dressing which, of course, as Sandy has mentioned a number of times, really helps with visibility and regular assessment. And just like any other transparent film, they are breathable and fluid impermeable. And I think most importantly, especially for these at-risk patients, they're gentle on the skin and atraumatic to remove. The second product in the vascular access line of dressings is our silicone CovaClear IV dressing. It is very similar, almost identical, would look identical outside of the packaging. It just does not contain the chlorhexidine and silver. So for those patients who may have an existing MARSI, this is a really, really gentle option without the presence of any chemical ingredient. And it offers all the same benefits of a standard and regular IV dressing with the transparency, breathability, and of course, it's a barrier because it is fluid impermeable. So I know Sandy knows these technologies well and knows silicones very well. So I'll pass it back to her for any last comments and just a few brief slides to summarize and then we'll wrap it up.

Yes. So I love the options that the silicone dressing gives because it's atraumatic. It is not painful when you remove it. They're using less chlorhexidine to prevent the incidents of chlorhexidine-irritant contact dermatitis. The lowest possible chlorhexidine that you need. And with the silver incorporated in it -- to that, it leverages the synergistic effect of both of those products. And it's an all-in one antimicrobial design. So you're not having to go get the disk, you're not having to go get the dressing, and then you drop the disk and all those things that you are planning on, it's like one-stop shopping. I really, really like it a lot and it's proved to be very beneficial. The skin heals from the inside out. And so if you have a scrape on your knee or anything like that, why do we cover it with a Band-Aid is because we know that the skin is going to heal from the inside out. And when you take that Band-Aid off, it's going to look better. The same goes for if you put that silicone on it, and you're not retraumatizing that wound or that irritant that was on there, the skin will do its job and the skin will heal while that silicone dressing is in place for 7 days. So in summary, MARSI is prevalent, but it's very underappreciated complication that impacts the patient outcomes, satisfaction, their quality of life and adding to our stress and burnout as providers and clinicians. It is preventable with best practices and approaches that account for the individual patient needs. I cannot stress this enough that you -- your institutions should have a standard of care, whatever that standard of care is for CLABSI. But as a nurse, I have the knowledge to make a clinical decision when I see something that is unanticipated or unexpected. And I have to then make a clinical decision that, "okay, this standard dressing is not appropriate for this patient anymore. And therefore, I need a tool and alternative that I can provide this patient so as not to inflict more harm on them." And so the innovative technology just helps us prevent MARSI and through compassionate and patient-centered care because that's what we want to do, is just have better outcomes and have the ability to provide that for the patient and the families. You're still on mute, Kate. Sorry about that.

Sorry about that, everyone. I was saying thank you very much, Sandy, for taking the time to share your expertise with us and take us through this content on what I believe is really such an important topic. We have amazing engagement in the chat from everyone, and I want to thank you all for coming to the webinar today and for engaging through the chat. There are a number of questions here, and I know we are just at 2 minutes till 2:00 p.m. So I see some about different sizes and another one from Chris about the use of barriers with the silicones because they are silicones and they're intended and designed to really interact very closely within the grooves and the valleys of the skin's topography. They -- we recommend not using any barrier products before you apply those. There are a number of questions here that we're just unfortunately not going to have time to get to today. But we have your information and we have your questions, and we will reach out to you to provide answers very soon. I also just wanted to remind everyone that a recording of this webinar will be available and we really encourage you, if you were a little late getting here or if you've got a colleague who you think would like to see it but couldn't make it today, please share it with them or have them reach out to us at [email protected]. Lastly, if you have feedback for us on today's webinar, we would love to hear from you. We're going to keep our webinar series going and we'll be announcing additional topics. Probably staying very focused on the skin, skin integrity and vascular access care for the next few. But we would love to hear your thoughts on what we should cover and what you thought of today's webinar. So I will leave it there at 1:59 -- 2:00 p.m. now, and thank you, everyone, again, for coming, and have a great day.