Prevention of Central Line-Associated Bloodstream Infections

Prevention of Central Line-Associated Bloodstream Infections (CLABSIs)

Submitted by

Kerry Sean Murphy

DPI Project Proposal Chapter 2 – Literature Review

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

Prevention of Central Line-Associated Bloodstream Infections (CLABSIs) 1

Prevention of Central Line-Associated Bloodstream Infections (CLABSIs)

July 17, 2019

Chapter 2: Literature Review


The Purpose of this study project is to explore the problem of CLABSIs and examine available measures to prevent, control and reduce incidences. In particular, this project proposes teaching proper CVC maintenance as the intervention to prevent CLABSI. In addition to the educational interventions, evidence-based practices such as care bundles which include elements such as using chlorhexidine for proper clean-up of the sight of insertion, proper hand hygiene, and ensuring that the catheter is removed as soon as it is no longer needed. Another intervention proposed in this project is monitoring and appropriate inspection of all procedures around CVC processes. With this in mind, this literature review section will sample various studies which have been done with regard to prevention of CLABSI. Past studies which have been done in this area will be analyzed with more attention being paid to the methodology used, the results, and the solutions they proposed. This section of the project will analyze the theoretical foundations of the approach used, the review of literature, and the key themes which will guide the projectstudy. After choosing the topic, the databases from which the searches will be conducted were identified. The searches were then conducted with the key words being “management and prevention of CLABSIs.” The references and bibliographies of research studies found were used to locate others. Comment by Kathryn Flynn: Educational sessions are not enough for a DNP project, per AQR. EBP interventions should be used to support project.

A total of 200 articles with researches and findings about CVCs, their risk factors, CLABSIs, interventions, and the benefits of preventive measures when handling ICU patients with CVC insertions were identified to be used as references for this project. were established to talk about the CVCs, CLABSIs, risk factors, intervention, and benefits of preventive measures. Through inclusion and exclusion criteria many journal articles were left out because of being written in other languages rather than English. Therefore, the use of the English language index the Cumulative Index of Nursing and Allied Health Literature (CINAHL) was used to search related journal articles. Other search tools include The National Center for Biotechnology Information (NCBI) – PubMed. Studies older than five years were excluded to ensure that the research project remained current and up to date. Using real-time cases or conditions helps to improve the quality and validity of the resulted studies. Comment by Kathryn Flynn: Fix sentence Comment by Kathryn Flynn: clarify


Central Line-Associated Bloodstream Infection (CLABSIs) iins a fatal infection that results from bacteria or viruses entering the bloodstream through the central line. A central line, also known as a central venous catheter (CVC), refers to a tube used by doctors to administer medication, fluids or to collect blood from the body of a patient (Deason & Gray, 2018). CLABSIs are among the leading causes of deaths each year in different countries across the globe. These types of infections have been an area of interest for many healthcare researchers representing a diverse body of knowledge about the infection while still expanding on what is already known. This section of the research project is an analysis of articles related to CLABSIs with the significant themes of concern to the authors including risk factors, interventions, CLABSIs and Hospital Acquired Infections (HAIs), benefits of the preventive measures and the common symptoms of CLABSIs. Several interventions have been suggested for prevention of CLABSIs, but practitioners do not seem to apply the interventions appropriately. This explains why there are still a significant number of infections despite the interventions. This project seeks to bridge this gap by introducing educational interventions and evidence-based practices. A quick survey of the literature indicates that many scholars have investigated various prevention measures but none has explored training on CLABSIs maintenance bundle as a preventive measure. This is the gap that this project seeks to fill. Comment by Kathryn Flynn: sp Comment by Kathryn Flynn: delete; don’t incriminate yourself

Criterion Learner Score (0, 1, 2, or 3) Chairperson Score (0, 1, 2, or 3) Comments or Feedback
Introduction (to the Chapter) and Background (to the Problem)

This section describes the overall topic to be investigated, outlines the approach taken for the literature review, and defines the evolution of the problem based on the gap or need defined in the literature from its origination to its current form.

2 21 You’ll develop this section according to feedback in Chapter one when you submit it. Keep lit review focused on project specifics, not just infection in general.
Introduction states the overall purpose of the project. 2 21
Introduction provides an orienting paragraph so the reader knows what the literature review will address. 2 21
Introduction describes how the chapter will be organized (including the specific sections and subsections). 2 1
Introduction describes how the literature was surveyed so the reader can evaluate the thoroughness of the review. 2 1 Please do this
Background provides the historical overview of the problem based on the gap or need defined in the literature and how it originated. 2 21 Develop specifics according to Ch 1 modifications
Background discusses how the problem has evolved historically into its current form. 2 1 Develop; say why project is needed. They are not preventing infections now?
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format. 2 2
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document.

Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).

Theoretical Foundations

The Quality Health Outcomes Model (QHOM) is used to study healthcare quality and outlines relationships existing betweeen interventions, characteristics and outcomes of patients, and the characteristics of the healthcare system. This model/framework has been used by various researchers to test the effectiveness of infection prevention measures, for instance by Gilmartin and Sousa (2016). The QHOM theoretical framework has been increasingly forming the conceptual framework for projects projects which assess quality and system interventions for care improvement. Providing high quality healthcare services is the interest of every health care provider. Even ancient renowned philosophers such as Plato and Aristotle identified quality as one of the “great ideas.” The question of how quantity can be quantified has been under discussion for a long time. The QHOM is one of the models proposed to quantify the quality of healthcare (Mitchell & Lang, 2004). The model can be used to show the relationship between adherence to CLABSI prevention interventions as demonstrated by Gilmartin and Sousa (2016). This model will effectively be used by the researcher to answer the fundamental question asked in this studyproject: How does staff training of proper CVC maintenance and the use of evidence-based care bundles which include elements such as using chlorhexidine for proper clean-up of the sight of insertion, proper hand hygiene, and ensuring that the catheter is removed as soon as it is no longer needed, monitoring and appropriate inspections reduce the incidence of CLABSIs? Comment by Kathryn Flynn: Need to include specifics on how you will integrate into your project Comment by Kathryn Flynn: Be used by the researcher to.. Comment by Kathryn Flynn: EB best practice Comment by Kathryn Flynn: Delete; subjective

Criterion Learner Score (0, 1, 2, or 3) Chairperson Score (0, 1, 2, or 3) Comments or Feedback
theoretical Foundations

This section identifies the theories or models that provide the foundation for the project. This section should present the theories or models(s) and explain how the problem under investigation relates to the theory or model. The theories or models(s) guide the clinical questions and justify what is being measured (variables) as well as how those variables are related.

2 2
This section identifies and describes the theories or models to be used as the foundation for the project. 2 1 Develop how/ why you’ll use it
This section identifies and describes the seminal source for each theory or model. 2 1 Develop; seminal means first. Who devekoped theory and for what?
This section discusses how the clinical question(s) align with the respective theories or models. 2 21 develop
This section illustrates how the project fits within other evidence-based on the theory or model. 2 11 develop
This section reflects understanding of the theory or model and its relevance to the project. 2 1 clarify
This section cites references reflecting the foundational, historical, and current literature in the field. 2 11 Need more than one
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format. 22 21
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document.

Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).

Review of the Literature

Kadium (2015) inquired into how the education program for one month, based on the evidence-based guidelines recommended by CDC, will improve registered dialysis nurses’ knowledge regarding CVC maintenance care. Other researchers who have focused on how education, experience, and workshops enhance prevention or reduction of CVC infections include; El-Sol and& Badawy (2017), Leistner, et al. (2016), and Soffle, Hayes, &and Smith (2018). Dougherty (2015) highlights the potential of careful setting an organizational culture that cares for the patients. They suggest that a strong organizational culture that stresses care for the patients is key in reducing CLABSIs cases. Further, these researchers propose that education, simulated training, experience, and knowledge are critical aspects in the management of CLABSI infections. Comment by Kathryn Flynn: ‘and’ for multiple authors in narrative. & in ( ) Comment by Kathryn Flynn: I would add all these to your interventions and this article would justify use. In fact, say it here. Comment by Kerry Murphy: Sorry, I missed this – I beg your pardon please Comment by Kathryn Flynn: Ok, say here’ the research note will be the basis for project interventions…’

Studies by Xu, and& Wu (2017), Commonwealth of Australia (2015), Kadium (2015), Morrison, Raffaele and& Brennaman (2016), Tomar, et al. (2016), Lin, et al. (2015), and Esposito, Guillari and& Angelillo (2017) all concur with O’Grady, et al. (2015) underscored the importance of establishing the role of monitoring and appropriate inspection of the CVC site in studies regarding CLABSI. Various researchers have investigated the CLABSI-related preventive measures implemented among adult patients hospitalized in an ICU setting. These include studies by Perin, et al. (2016), Jones, et al. (2017), Masse, Edmond, and& Diekema (2018), and Oliveira, et al. (2016). Basinger (2015) investigated the use of comprehensive unit-based safety programs (CUSP) in improving the safety culture within ICUs and achieve the goal of reducing or eliminating CLABSIs. In Basinger’s report, the cases of CLABSIs reported were recorded before and after the introduction and execution of the CUSP program. The CUSP is a program designed to teach and enhance patient safety awareness as well as the quality of nursing care. This program is implemented in a five-stage process that starts with providing education on safety science, followed by the identification of weaknesses and risks in patient safety, then the partnering of senior executive with a unit, learning from the flaws, and the execution of communication and teamwork tools (Basinger, 2015). From the project, it was observed that the number of CLABSI cases reduced after the implementation of CUSP as an intervention measure. Other studies such as in Kadium (2015) and Powell (2018) have investigated the effect of knowledge and education of the family and patient in CLABSIs prevention. Preventive measures are a core motive as to why the studies in CVC and CLABSI are conducted. Comment by Kathryn Flynn: . All Comment by Kathryn Flynn: Add this to your interventions Comment by Kathryn Flynn: Explain more about the program

Theme 1: Risk Factors Associated with CLABSIs.

Subtheme 1: Contamination on Insertion This is related to my intervention in the sense that maintenance bundles are applicable in every step of handling the CVC, including the insertion stage. Duly observation of all the elements described in the maintenance bundle will reduce or eliminate contamination on insertion. The catheter may gain entry into the bloodstream during the insertion of the line into the body of the patient. The rate of infections during insertion is substantially dependent on the hygiene levels that are put in place by the health care providers (Dick et al., 2015). In the project by Dick et al., (2015), there are no clear clinical questions. The projectstudy used Medicare data combined with healthcare-associated infections for the prior five years. It was found that healthcare-associated infection prevention programs which are multifaceted are cost-effective. In the study, it is also noted that contamination on insertion is one of the biggest risk factors associated with CLABSI infections. Comment by Kathryn Flynn: Explain how this relates to your intervention. You decided to take the insertion part out, so if you are leaving this review in, show why it is significant to your project. Comment by Kathryn Flynn: What involved?

Subtheme 2. Contaminated Skin of the Patient

The insertion is done on the body of the patient. Infected skin of the patient may contain microorganisms which may enter the body during the insertion (Dombecki et al., 2017). The fact that patients have negligible knowledge concerning the different ways the infection may occur means that there is so much responsibility placed on the health caregivers. The infection rates due to unsanitary practices of the patients seem to have drawn the attention of the authors of the different articles analyzed. With the rates of CLABSIs rising each year, mortality rates have also increased. Researchers have made CLABSIs prevention a priority to address such risk factors to avoid or reduce infection rates. Skin Hygiene of the patients requires additional care for the prevention of CLABSIs. Comment by Kathryn Flynn: See comments above; insertion and why is it significant? Comment by Kerry Murphy: Okay, I have stated the significance of involving insertion above

Subtheme 2. Non-Compliance with the Central Line Maintenance

There are guidelines for healthcare professionals meant to reduce the chances of CLABSIs infection. Such instructions include not using antiseptics and ensuring complete dressing changes (Orwoll et al., 2017). As much as these guidelines and policies are in place does not mean that compliance is definite. Cases of caregivers who do not comply with the stipulated guidelines are common and such levels of unprofessionalism have cost patients their lives. There is evidence that the absence of compliance leads to deleterious issues among patients using the CVC.

Theme 2. Interventions

a. Removal of Unnecessary Lines Comment by Kathryn Flynn: There should be articles fully reviewed in each subtheme section. Only one citation, not article in this section.

ResearchersThe authors agree that there are times patients will have lines which are no longer being used for any medical purpose (Janum & Afshari, 2016). These are mainly patients who have spent so much time in the hospitals, and the chances of being discharged seem minimal (Sodek, 2016). The caregivers are meant to remove lines once they have served the purpose. The more these lines remain on the body of the patients the more the chances of infection. Bacteria and all other associated microorganisms will quickly enter the body. I am including this theme as part of the project with the understanding that the process of prompt removal of CVCs which are no longer in use is part of the CVC maintenance bundle. Comment by Kathryn Flynn: Ok, cite Comment by Kathryn Flynn: Does this topic relate to your interventions? Explain. Integrate this chapter into other chapters’ info.

b. Health Care Providers to Follow Recommendations Comment by Kathryn Flynn: There should be articles fully reviewed in each subtheme section. Only one citation, not article in this section. Comment by Kathryn Flynn: Add another research article.

Healthcare professionals are trained on the best practices that are meant to ensure that the chances of patient infections are minimized or even eliminated. Unfamiliarity will occur at times, and the well-being of the patients is jeopardized (Stone et al., 2016). Just like any other profession, health care ties it’s professionals around practices which ensure ethical undertakings to safeguard the lives of the patients. The authors encourage the idea that healthcare professionals should be unbiased to patients and do what their work ethics dictates them to do. Such will ensure improved the health and safety of the patients (Ling, et al., 2016). Comment by Kathryn Flynn: What authors? Rephrase this sentence to clarify.Stone? Cite Comment by Kathryn Flynn: Not clear what Ling has said or written. Rephrase.

c. Encouraging Teamwork Comment by Kathryn Flynn: There should be articles fully reviewed in each subtheme section. Only one citation, not article in this section.

In any health care setting, there are two main participants. These are the health caregivers and patients. One of the authors suggests that teamwork between these two parties will go a long way in reducing the rates of these infections (Stone et al., 2016). Collaboration will ensure that there is knowledge sharing, that key concerns and risks that may be known to one of the parties are made known to the other (Basinger, 2015). The impact teamwork will have on preventing the cases of CLABSIs in hospitals is immeasurable. The same should be embraced and upheld. The understanding of the intervention process serves as a variable building model as well as a methodological process in studies on CLABSI.

Implementation of policy and surveillance

According to Namita et al., (2015) cooperation between nurses and the patient, e-learning, confidence offers better care for the CVC. Besides, checking pre and post-treatment axillary temperature, keeping the dressing closing, close monitoring of the patient, using aseptic technique, and maintaining CVC through anticoagulant as well as using polyurethane dressing with an external cloth border instead of polyvinylchloride catheter dressing reduce infection. In another study by Commonwealth of Australia, (2016) CLABSI surveillance has to offer a correct definition, blood culture, health-associated infection or HAI-non-inpatient and settings which are often; oncology, hematology, ICU, hospital-wide, high dependency units, and hemodialysis patient. Furthermore, the right timing, correct interpretation, and potential organisms should be established for surveillance to serve in reducing infections in CVC units. According to Tomlinson (2015) the study conducted on the effect of surveillance, in 6 months, the application of interventions right line, right time enhanced reduction on infections. Morrison, Raffaele, and & Brennaman (2016) to indicate that there is always improvement in service when nurses are given feedback on the CLABSI and risk factors. Out of 620 visually audited lines from 14 nursing units for 16 weeks, 113 lines did not audit. 628 risk factors were established. Through personalized nurse report cards infections decrease. Baldassarre et al. (2015) note when audit tools are used alongside education the compliance of nurses increases. Furthermore, Jones et al. (2017) state that repeated skill assessment enhances the safety of patients with CVC.


El-Sol, and A., & Badawy, A.I. (2017) studies how education module affects CABSI and indicates that most of the participants had a diploma in nursing and lacked proper practice for CVC. The pre-and post-education mean scores varied before and after training. It was established that knowledge, experience, and practice positively resulted in lower infections. The population used in the study by El-Sol and Badawy (2017) included nurses and this is similar to the population I am planning to use in this project. Comment by Kathryn Flynn: Is this population related to yours? Synthesize why this article is important if some variables are dissimilar.

Other interventions

Aloushi, S.M. and& Alsarai, F.A. (2018) opine that as long as the nurse-patientercent ration was lowered, compliance will improve, thus reducing the likelihood of CVC infections. the compliance in the patient’s outcome. Perin et al. (2016) postulate that hand hygiene and maximal barrier precautions; multidimensional programs and strategies such as impregnated catheters and bandages and the involvement and commitment of staff to preventing infections. Hand hygiene and maximal barrier precautions are part of maintenance bundle, thus integral components of evidence-based intervention proposed in this project. Comment by Kathryn Flynn: ? Comment by Kathryn Flynn: Ok, will this be part of your interventions? Mention.

CLABSIs associated infections/Transmissions

a. Hematogenous Transmission

This is an infection that is characterized by a primary tumor penetrating blood vessels. They then get transported in the blood vessels and eventually into the distant parts of the body of the patient (Stone et al., 2016). Once at the distant sites, the cells will penetrate the walls of the vessels again and build a basis for another, a new tumor on the new site. Such are the same cases that happen with CLABSIs. Examples include catheter-associated Urinary Tract Infections (CAUTI) that can lead to CLABSI’s.

b. Catheter-associated Urinary Tract Infections (CAUTI)

A urinary tract infection (UTI) refers to an infection in any part of the urinary system. UTIs are also common healthcare-associated infections reported by both patients and healthcare givers. These infections are associated with urinary catheters, a tube which is used by doctors through the urethra to drain urine (Douglas, 2015). Most of the hospitalized patients end up with urinary catheters inserted in their bladder. Prolonged use of the catheters increases the risks of the infections. Health caregivers should ensure that these catheters are removed when not being used to reduce the risk of patients contracting the CLABSIs. In another study by Tenke, Köves,and Johansen (2014), it is suggested that the best way to prevent UTIs caused by insertion of catheters is to remove the catheters which are no longer in use as soon as possible. Comment by Kathryn Flynn: The paragraph doesn’t support your assertion. Need more article evidence.

c. Contaminated Infusates

The term refers to the introduction of pathogens into the body of patients through fluids intravenously introduced into the body. The introduction of these pathogens occurs through the sterile used by the health care providers. During surgery or during other procedures which may require line insertion, bacteria may be introduced into the body of the patient (Stone et al., 2016). Contaminated infuscate happen to be one of the ways CLABSIs bacteria is introduced into the bloodstream. Patients and the health care providers need to be educated on such risks. Comment by Kathryn Flynn: ? clarify Comment by Kathryn Flynn: Ok, but you are not focusing on insertion, correct? Comment by Kerry Murphy: Yes, I am not focusing on insertion but I will use the safety concept and measures around it to discuss maintenance bundles for CLABSIs Comment by Kathryn Flynn: Ok, reiterate that in areas.

Necessity for Interventions

a. Reduced incidences of CLABSIs Comment by Kathryn Flynn: There should be articles fully reviewed in each subtheme section. Only one citation, not article in this section.

The preventive measures mentioned above by the authors of the different articles will go a long way into reducing the incidents that are reported by patients and caregivers concerning CLABSIs (Klintworth et al., 2015). Encouraging adherence to the hygiene standards, the policies and the recommendations as they relate to CLABSIs infections will enable the creation of an environment that will enhance the well-being of the patients and also minimize the chances of contraction of the infections. CLABS is deadly and is already costing patients and nations profoundly. Research has reliably shown that when evidence-based interventions are applied in form of bundles, they are likely to significantly reduce incidences of CLABSIs (Hussain, et al., 2017). This is in line with the overall purpose of this project, which is to prevent CLABSIs through maintenance bundle.

b. Reduced morbidity Comment by Kathryn Flynn: There should be articles fully reviewed in each subtheme section. Only one citation, not article in this section.

Morbidity has been defined as how often a disease occurs or is reported in a population. The morbidity rate is determined by examining the number of patients with a particular disease at a given period (Kim & Biorn, 2017). Reduced cases of disease mean that preventive and treatment measures are effectively implemented by all stakeholders involved. CLABSIs infections are no exceptions here. The literature work of the previous authors appreciates that the health care institutions that have adopted the interventions measures above report few and reduced cases of the infection. As such, many studies show that the impact of reducing infection rates is reducing morbidity which shows an improvement in the quality of care in hospitals. It serves in demonstrating the significance of the study project as well as a variable. Since CLABSIs are associated with an increased morbidity rates (Perl, et al., 2014), any intervention to reduce or eliminate such infections will also lead to reduced deaths.

Safe Costs Containment and Maintaining Profits

In one study by Scott, Sinkowitz-Cochran, Wise, Baggs, and& Goates, (2016) indicates that in a study on 40,556 and 75,067 central line-associated bloodstream infections were prevented in Medicare and Medicaid patients in critical care units in the period 1990-2008 with about $ 586-$862 million expenditure and control efforts that lead to saving $44–$131 with net profits of about 664 USD Million. Cost containment and cost saving are one of the motivating factors in the studies on CLABSI prevention.

CLABSIs Symptoms

a. Site Discharge

The area where the catheter is placed should remain dry, and no discharge should be coming from the area. Some patients, however, may notice yellow or green discharge (Conley et al., 2018). The drainage should be a cause for alarm, and the authors have identified the discharges as some of the top indicators that something has gone wrong and healthcare providers should act up. Discharges show that the area is not fresh and has been exposed to bacteria and microorganisms, something that should be of great concern. Comment by Kathryn Flynn: There should be articles fully reviewed in each subtheme section. Only one citation, not article in this section. Comment by Kathryn Flynn: There should be a better article cited here.

b. Site Swelling

Patients may experience additional swelling at the place where the catheter line has been inserted. The swelling is an indicator that there is no healing that is taking place and that there is every reason to worry about the well-being of the patient (Castagna et al., 2016). It is recommended that The authors suggest that nurses should give attention to the recovery process of patients and ensure that such instances are noted and addressed. Patients may report pain, swelling, or discharge from the exit site and redness surrounding the exit site or along the subcutaneous track when exit site or tunnel infections are present (Haddadin & Regunath, 2019). In cases where there is no close relationship between the health caregivers and the patients, such incidents may be hard to notice, and patients ended up suffering harm and exposed to infections which can be fatal. Comment by Kathryn Flynn: There should be articles fully reviewed in each subtheme section. Only one citation, not article in this section.Full review and not just one generalized sentence..

c. Site Redness

A patient may develop red streaks at the area where the line has been inserted. Another warning sign that the patient may be headed to a CLABSIs (Haddadin & Regunath, 2019). Again, if there is no close interaction between patients and their caregivers such may be hard to notice (Chesshyre et al., 2015). Also concerning is if the patient is not aware of what are causes for alarm such as sites and signs of infection. They may never report the same and end up risking their lives. Adult patients and children are at the highest risk of these symptoms because in most cases the patient does not know what should be reported to the healthcare provider and what should not be a cause for concern. Comment by Kathryn Flynn: There should be articles fully reviewed in each subtheme section. Only one citation, not article in this section.

Sample Populations Comment by Kathryn Flynn: Organize this section with either subheadings or organized paragraphs that are formed with intro, conclusion sentences, and logically flowing contents within.

The authors have utilized different study populations to accomplish their objectives. The two major categories sample populations used in these studies include of respondents that are common to all authors are healthcare professionals and adult patients suffering from or who have suffered CLABSIs infections in the past (Hsu et al., 2016). These two categories have a rich knowledge of the study topic. Such enables researchers to collect adequate data for their research topics and also draw logical conclusions. Other researchers sampled past researches using predetermined search criteria. Comment by Kathryn Flynn: Clarify what you mean.

Sampling based on past studies

There are several processes through which people sample information in studies. For Alfonso et al. (2016) the search of the various database using key terms gave 291 records, however, based on relevance only four articles were suitable for the studyproject. Xu and& Wu (2017) established 400 studies to establish the various types of catheters and the level of risk each gives. Similarly, Scott II et al. (2016) , Sinkowits-Cochra, Wise, Baggs, & Goats (2016) utilized Medicare and Medicaid data from 1990-2008 to establish the cost saving after implementing preventive measures against CABSI. As for Perin et al. (2016), 28 out of the 34 articles found had there was the use of 34 studies, but only 28 offered significant information for results in measuring CVC insertion and maintenance strategies. The study by Lin et al. (2015) utilized a cross-sectional design in the qualitative analysis of sources based on the key concepts of the study. Perin et al. (2016) explored a purposive sampling and selection of 34 studies that formed a set through which to assess results after a systematic review of academic and health database.

Sampling based on health workers and patients

Soffle, Hayes, and& Smith (2018) used a sample population of 20 traditional education and 78 for simulated-based teaching methods in establishing their efficiency in practical-based knowledge on prevention of CABSI. As for Namita et al., (2015) there was the use of 10 articles through which a deep study was done. In a study by Dougherty (2015), there was convenience sampling of a population of registered nurses in a long-term acute care hospital (LTACH) setting after completion of orientation to the unit. Out of 52 eligible nurses, 31 participated in the survey response. In Viana Taveira, Lima, De Araújo, and& De Mello (2016) the sample included 188 children in pediatric cancer health care. While Leitine et al. (2016) put to use the very low birth weight (VLBW) newborns from NICUs who took part in the German nosocomial infection surveillance system for ventilated preterm infants from Jan 2008-2009. In a study by Elsol and& Badawy (2017), there was convenience sampling with 44 nurses working in ICU who filled the questionnaire on demographic and CABSI related questions and observational checklist. For Aloushi and& Alsarai (2018) is 171 ICU nurses in 15 hospitals within 15 hospitals in 5 cities of Jordan. The nurses were supposed to be registered, working as a full-time in the ICU; and with at least one year of experience. A panel of experts comprising members of 3 nursing faculties, two infection control specialists and 5 ICU nurses participated in the validation of the initial draft of the instrument, which contained 13 items. The mean age of the participants was 32.5 years; 32.7 for males, and 31.5 for females. Seventy-two participants (43%) had no previous education about CLABSI prevention guidelines, and 154 (90%) reported a lack of supplies in their hospital, such as antibiotic-impregnated central venous catheters. In the study by Morris et al. (2016), there was the utilization of 715 beds in the 2-campus acute care community hospital healthcare system in Southwest Florida.

The study by Lin et al. (2015) utilized a cross-sectional design in the qualitative analysis of sources based on the key concepts of the study. Perin et al. (2016) explored a purposive sampling and selection of 34 studies that formed a set through which to assess results after a systematic review of academic and health database. In the sampling process, Esposito (2017) utilized a cross-sectional design in 16 non-teaching and teaching public and private hospitals with units utilizing CVCs for adult oncological patients. The target group was 472 nurses in the oncology and outpatient chemotherapy units of the selected hospitals.

In the study by Likewise, Oliveria et al. (2016), samples were collected through a cross-sectional study with questionnaires to 76 professionals in intensive care. Zu and& Wu (2017) utilized the qualitative process and a systematic search of databased on CINAHL, ABI INFORM, and OVID through which they established more than a hundred articles before applying the exclusion-inclusion criteria and utilizing ten articles in the study. WHO (2018) held comprehensive research in various facilities to establish methods of improving infection prevention and control on catheter units. Bianco et al. (2015) used samples from some CLABSIs which were collected by the hospital-based IP in line with the NHAN approach and definition of CLABIs. The CUSP teams of hospitals receive monthly feedback on infections and quarterly feedback on rates of infection per 1,000 catheter days. Basinger (2016) samples were collected through a cross-sectional study with questionnaires to 76 professionals of varied gender, and ages in intensive care. In another study by Chidambaram (2015) the samples used were acquired from existent studies.

On the other hand, Kadium (2015) utilized a convenience sampling of registered dialysis nurses in the hemodialysis unit was used in a pre and post-test instructional interventional design among 60 registered dialysis nurses. Tomilnson (2015) focused on the population of inpatients who had peripheral IV therapy for 5-29 days within a 600-bed community hospital. Whereas Pepin et al. (2015) utilized patients aged 18 and more in the ICU with CVCs. Eligible participants had to have a central line for 48 hours and without prior CLABSI. In a study by Tomars et al. (2016), there was a study using children who stayed in PICU for more than 48 hours without infection at the time of admission. The study involved 265 children.

Other more studies include, Powell (2018) investigated information from 20 patients, three of whom were children and the rest adults. Masse, Edmond, and& Diekema (2018) surveyed information from a literature review of studies ranging from 2008 to data to establish the infection prevention approaches performed outside the operating room. In most of the studies, the aspects of age, gender, and marital status were never necessary for the study. The focus was on the usage of the CVCs.

As observed from sampling, some studies go for the available literature which requires careful evaluation of sources and critical analysis of results. On the other hand, some studies involve the nurses or observations in the hospitals. In practical studies, the uses of large samples, using collection methods that do not reveal to nurses the study is going on and observation of every detail of handling the patients as well as demographic information of both the patients and nurses is essential.


There are several apparent limitations in the studies. For example, Esposito et al. (2017) opine that self-reported questionnaires affected accuracy in response, most respondents gave information that was positive rather than genitive on hygienic consideration of CVCs. Questionnaires ought to be anonymous to encourage correct reporting. He also notes that a cross-sectional study hindered establishing a causative relationship with outcomes of interest. Future studies need to focus on non-evidence-based practices and dressing of catheters and how they relate with CLABSI (Han et al., 2015). Also, the study by Basinger (2014) was limited by failure to separate the efforts that aim at improving the use of CUSP, related approaches, and technologies that reduce compliance in hygiene situations of CVC. Comment by Kathryn Flynn: Ok, is this what you are using? Explain, clarify, then support with articles. Comment by Kerry Murphy: I have not yet decided which particular tool I will use; I have several in mind. Here, I am trying to discuss the limitations of the studies analyzed above Comment by Kathryn Flynn: You’ll have to add the tool in this chapter. It’s time; I need to review.

In the study by Afonso et al. (2015) the limitation was in the use of cumulative analysis on line-associated HABSI types while reporting the catheter culture is a diagnosis of infection lead to difficulties in isolating categorical data on attitudes, knowledge, and practical application of knowledge. Moreover, another study by Lin et al. (2015) showed that the limited time and consideration of barrier towards quality, an aspect that needed adequate time hindered acquisition of enough information. Other researchers who complained of time that limited them from acquiring adequate and reliable data as well as having comprehensive studies include Kadium (2015), Pepin et al. (2015) Aloushi and& Alsarai (2018). Therefore, it resulted in results that were not matching with the literature review and they could not be generalized on any other population Furthermore, Perin et al. (2016) note that the use of one type of catheter hindered generalization of information to other health departments.

Chidambaram (2015) assert that there was limited evidence as a result of the utilization of the exploratory method when conducting a study on CLABSIs hence a lot of data never emerged clearly. According to Kadium (2015) the small sample size and short duration within which it was conducted limited the results that were acquired. Another problem emerged because there was no assessment of the learning styles of the patients. According to Powell (2018), some electronically captured information gave collinearity that challenged in the interpretation of results. In other studies, location-based data was limited and focus on one type of catheter limited the generalization of results on every catheter (Perin et al., 2016). From reviewing the limitations of various studies, it is clear that the methods used, the population, the duration of the study, the number of aspects observed, and interpretation affects the quality of the findings.

Conclusions and Recommendations Comment by Kathryn Flynn: Ok, this should be a synthesis of everything above. You seem to have more data down below than up above. Organize literature by themes, subthemes, form into paragraphs that are clear and cogent.

Overall, there are various issues that are addressed in the various papers in this analysis. From the literature review, it is observed that fighting CLABSI results in saving a lot of money that could be used by the healthcare in other projects (Scott, Sinkowitz-Cochran, Wise, Baggs, and& Goates, 2016). Afonso et al. (2016) conclude that hospitals achieve zero infections of CLABSI rates meaning the continued usage of surveillance together with a washcloth bathing for they curtail Gram-positive bacteria. Similarly, Namita et al., (2015), besides, Viana Taviera et al., (2016) remind the health care practitioners on assessing other risks such as white blood cell content, malnutrition status, bone marrow aplasia, and CVC risks before chemotherapy because they increase the risks of infection among children. Thus, hospitals with high baseline hygienic standards of care and lower CLABSI rates might benefit less fromchlorhexidine gluconate (CHG) washcloth bathing. Additionally, Lin et al. (2016) note that the adherence to the current evidence-based practice guidelines, education, and consideration or compliance to hygiene, and use of chlorhexidine antiseptic bathing instead of the soap helps in the prevention of CLABSIs. For example, according to O’Grady et al. (2015), maximal sterile, cautious insertion of catheters, avoidance of routine catheter replacement, usage of the antiseptic/antibiotic impregnated short-term central venous catheters and chlorhexidine-impregnated sponge dressings help to prevent and manage CLABSIs. Comment by Kathryn Flynn: sp Comment by Kathryn Flynn: cost savings, improved health outcomes and population health.

Similarly, Perin et al., (2016) opine that the consideration of necessary interventions on the catheters can prevent infections. Among such interventions is the proper selection and timing of the insertion of a CAVAD, intervention and the commitment of the clinical leader, reduce infection of CLABS (Tomilnson, 2015). The evaluate-treat order was an essential process in preventing infections. This evaluation could be through audit tools on awareness and compliance, together with policies like Stay connected and closed-circuit system in which proper maintenance of cars is ensured (Baldassarre, Finkelston, Decker, Lewis, and& Niesley, 2015). According to Esposito et al. (2017) in situations where nurses have a positive attitude, and perceive hygiene as a risk in CLABSIs as well as where evidence-based practice programs are used, infection is likely to be prevented. The reason behind the high infections is low adherence to handwashing. Xu and& Wu (2017) note that patient cooperation and knowledge of proper care for CVC prevent infections. There is a need for studying practical clinical nurse interventions in the care for CVC. In the study by Han et al. (2015) state that blood culture is necessary for managing CVC patients. Formal training, years of experience, written policies, enhance compliance with proper CVC care and reduce infections (Han et al., 2015). In a study by Bianco et al. (2015), there is a conclusion that less costly evidence-based education, CUSP prevent infections. It is also indicated that multidisciplinary education programs improve assistance to patients (Oliveira et al., 2016). Similarly, Soffle et al. (2018) suitable simulation program should have educational sessions, video training, problem-based learning, mixed methods, and appropriate timing. Besides, the management should be aware that some of the challenges to the program include; cost, space, time, faculty support among others. Comment by Kathryn Flynn: Is this sp right? Comment by Kathryn Flynn: All of the authors in this section should be in themes or subthemes section in order to be in summary and conclusion too.

According to Afonso et al. (2016), an analysis into the topic requires separate primary, secondary and central line-associated HABSI types in reporting catheter culture during the diagnosis of bloodstream infection that increases certainty and lowering of risks of bias as a result of improper attribution of blood culture contaminants.

The choice of catheters should also be carefully considered. According to Xu and& Wu (2017), the type of catheter, external and internal factors as well as the mode of infection is a critical element during the evaluation and care for CVC. Furthermore, Powell (2018) notes that if hospitals use surveillance for antimicrobial use and resistance options in ambulatory surgery and acute care hospitals, then infections will be eliminated. Pepin et al. (2015) indicate that the surveillance should be more critical among patients with any given comorbid conditions because they have a higher risk of CLABSI as compared with another patient. Morris et al. (2016) suggest that through central line audit analysis and provision of the unit case reports to nursing managers and 1-on-1 personalized nurse report cards there is increased compliance with established guidelines for the management of central lines. In the study by Chidambaram (2015), the conclusive view offers that the dental care process as necessary for pediatric CKD patients if studies on CVC are being held. Besides, CVC benefits CKD patients but poses a threat for long-term candidates due to negligence on disinfection and sterilization processes. According to Kadium (2015), high education levels do not affect pretest, but the completion of infection control course affects pretest scores.

Similarly, more experienced nurses, those registered in the dialysis nurse knowledge, those with updated knowledge on CVC care, offer better care for a patient with CVCs. Another argument is that evidence-based care allows students to work purposefully.

Moreover, the provision of continuous education enhanced retention and application of knowledge in tasks. In another study by Masse, Edmond, and& Diekema (2018) as expert opinion high-quality evidence practice through sufficient evidence via training and assessment result in proper care for patients with catheters. Ultimately, WHO (2018) suggests that as long as health care establishes a comprehensive action plan, assessment baseline, execution, checks the impact and establishes a sustainable long-term plan, CLABSI cases can be prevented. Aloushi and& Alsarai (2018) recommend having adequate nurses because it encourages them to be compliant to right practices. Tomar et al. (2016) give an overall observation that all central-line associated bloodstream infections can be prevented through the application of intervention strategist that target the primary bacteremia. Likewise, Leistner, Thürnagel, Schwab, Gastmeier, and& Geffers, (2016) recommends that infant units should have adequate nurses to reduce infection cases. It is thus necessary for future studies to focus on more than one type of catheter for results to be relevant to various departments of health.

From the above literature review, it is clear that evidence-based practice, policies, hygiene, education and attendance of workshops are essential aspects that need to be studied. Besides, the consideration of the study population, using adequate time for the study, having confidential questionnaires are part of the essentials of conducting a useful study on CVCs and CLABSI’s.

The conclusions and recommendations are drawn from what the authors had from their results. There is the need for continued monitoring and feedback concerning compliance with the set hygiene practices aimed at preventing CLABSIs infections. The infection basics, such as patient and healthcare providers’ education, should be addressed (Beverly et al., 2018). Public health funding has also been suggested as a recommendation towards the prevention of the infection. Further areas of the study should address different ways of tracking infections, whether they are high at the emergency rooms or the operation rooms. The areas for further research should also focus on strategies aimed at removing barriers in policies and practices. Comment by Kathryn Flynn: Kerry, the chapter needs organization, focus, clarity, synthesis of how it relates to your project. See comments, modify, resubmit when you have made all modifications, reviewed, aligned with prior work that has been approved, APA formatted, and re-read. Comment by Kathryn Flynn: This is better, but more works should be in themes and subthemes section, and conlusion and summary section should just hit on key components.

Criterion Learner Score (0, 1, 2, or 3) Chairperson Score (0, 1, 2, or 3) Comments or Feedback
Review of the Literature

This section provides a broad, balanced overview of the existing literature related to the project topic. It identifies themes, trends, and conflicts in evidence-based research methodology, design, and findings. It describes the literature in related topic areas and its relevance to the project topic. It provides an overall analysis of the existing literature examining the contributions of this literature to the field, identifying the conflicts, and relating the themes and results to the project. Citations are provided for all ideas, concepts, and perspectives. The investigator’s personal opinions or perspectives are not included.

2 2
Chapter 2 needs to be at least 20-25 pages in length. It needs to include a minimum of 50 scholarly sources with 85% from the sources published within the past 5 years. Additional sources do not necessarily need to be from the past 5 years. It should not include any personal perspectives. 2 2
This section describes each variable in the project discussing the prior evidence-based research that has been done on the variable. 2 2
This section Discusses the various methodologies and designs that have been used to understand evidence-based research topics related to the project. Uses this information to justify the design. 2 2 Create a theme; methodologies.
This section argues the appropriateness of the practice improvement project’s instruments, measures, and/or approaches used to collect data. 2 2
This section discusses topics related to the practice improvement project topic and may include (a) studies relating the variables (quantitative) or exploring related phenomena (qualitative), (b) evidence –based studies on related factors associated with the topic, (c) Relates the literature back to the DPI-project topic and the practice problem. d) studies on the instruments used to collect data, and (e) studies on the broad population for the project. Set of topics discussed in the Review of Literature demonstrates a comprehensive understanding of the broad area in which the topic exists. 2 2
Each section within the Review of Literature includes an introductory paragraph that explains why the particular topic was explored relative to the practice improvement project topic. 2 2
Each section within the Review of Literature requires a summary paragraph that (a) compares and contrasts alternative perspectives on the topic, (b) provides a summary of the themes relative to the topic discussed that emerged from the literature, and (c) identifies how themes are relevant to your practice improvement project topic. 2 2
The types of references that may be used in the literature review include empirical articles, a limited number of practice improvement projects, peer-reviewed or scholarly journal articles, and books that present cutting-edge views on a topic, research-based, or seminal works. 2 2
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format. 2 2 Continue with organization
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document

Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).


In this section, various works of literature regarding the subject of CLABSI are analyzed. These past studies were searched with the key theme of this project in mind: teaching proper CVC maintenance as the intervention to prevent CLABSI. The key theoretical foundation that can be applied in this case is identified as the Quality Health Outcomes Model (QHOM). This model has been used to study healthcare quality and outlines relationships existing between interventions, characteristics and outcomes of patients, and the characteristics of the healthcare system. This model/framework has been used by various researchers to test the effectiveness of infection prevention measures, for instance by Gilmartin and Sousa (2016). The key themes identified in this section include risk factors associated with CLABSIS (with subthemes such as contamination on insertion, contaminated skin of the patient, and non-compliance with the central line maintenance), intervention (with subthemes including removal of unnecessary lines, following recommendations by healthcare providers, and encouraging teamwork). Comment by Kathryn Flynn: Kerry, Good work; looks better. Continue organizing and new modifications. Add tool, then resubmit.


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Aloush, S., & Alsaraireh, F. (2018). Nurses’ compliance with central line-associated bloodstream infection prevention guidelines: an observational study. Saudi Medical Journal39(3), 273-279. doi:10.15537/smj.2018.3.21497

Baldassarre, D., Finkelston, G., Decker, M., Lewis, M.O., & Niesley, M.L. (2015). Fighting CLABSI: An Interdisciplinary Approach for Best Practice Outcome. Journal of Health Science, (2), 453-457. Retrieved from

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Beverly, A. L., Hill, M. M., Camins, B. C., & Lee, R. A. (2018). Decreasing CLABSI Incidence Associated with Decreasing MRSA Bacteremia LabID Incidence. American Journal of Infection Control46(6), S82. doi:10.1016/j.ajic.2018.04.160

Bianco, A., Coscarelli, P., Nobile, C. G., Pileggi, C., & Pavia, M. (2015). The reduction of risk in central line-associated bloodstream infections: Knowledge, attitudes, and evidence-based practices in health care workers. American Journal of Infection Control41(2), 107-112. doi:10.1016/j.ajic.2012.02.038

Castagna, H., Kawagoe, J., Gonçalves, P., Menezes, F., Toniolo, A., Silva, C., Correa, L. (2016). Active surveillance and safety organizational goals to reduce central line-associated bloodstream infections outside the intensive care unit: 9 years of experience. American Journal of Infection Control44(9), 1058-1060. doi:10.1016/j.ajic.2016.02.034

Chesshyre, E., Goff, Z., Bowen, A., & Carapetis, J. (2015). The prevention, diagnosis, and management of central venous line infections in children. Journal of Infection71, S59-S75. doi:10.1016/j.jinf.2015.04.029

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Deason, S., & Gray, P. (2018). Beyond the Walls: Infection Prevention Expands to the Outpatient Environment. American Journal of Infection Control46(6), S82. doi:10.1016/j.ajic.2018.04.159

Dick, A. W., Perencevich, E. N., Pogorzelska-Maziarz, M., Zwanziger, J., Larson, E. L., & Stone, P. W. (2015). A decade of investment in infection prevention: A cost-effectiveness analysis. American Journal of Infection Control43(1), 4-9. doi:10.1016/j.ajic.2014.07.014

Dombecki, C., Vercher, J., Valyko, A., Mills, J., & Washer, L. (2017). Implementation of a Central Line-associated Bloodstream Infection (CLABSI) Prevention Bundle for Adult Hematologic Malignancy and Bone Marrow Transplant Patients. American Journal of Infection Control45(6), S103. doi:10.1016/j.ajic.2017.04.166

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Esposito, M. G. (2017). Knowledge, attitudes, and practice on the prevention of central line-associated bloodstream infections among nurses in oncological care: A cross-sectional study in an area of southern Italy. PLoS One, 1-11. doi:e0180473.

Han, Z., Liang, S. Y., & Marschall, J. (2015). Current strategies for the prevention and management of central line-associated bloodstream infections. Infection and Drug Resistance, 147–163. Retrieved from

Hsu, Y., Weeks, K., Yang, T., Sawyer, M. D., & Marsteller, J. A. (2016). Impact of self-reported guideline compliance: Bloodstream infection prevention in a national collaborative. American Journal of Infection Control42(10), S191-S196. doi:10.1016/j.ajic.2014.05.010

Janum  S, Afshari  A. (2016). Central venous catheter (CVC) removal for patients of all ages with candidaemia. Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD011195. DOI: 10.1002/14651858.CD011195.pub2.

Jones, G. F., Forsyth, K., Jenewein, C. G., Ray, R. D., DiMarco, S., & Pugh, C. M. (2017). Research Residents’ perceptions of skill decay: Effects of repeated skills assessments and scenario difficulty. The American Journal of Surgery213(4), 631-636. doi:10.1016/j.amjsurg.2016.12.003

Kadium, M. J. (2015). Improving Nurses’ Knowledge to Reduce Catheter-Related Bloodstream Infection in Hemodialysis Unit. Retrieved from

Kim, R., & Biorn, J. (2017). Healthcare-Associated Clostridium difficile Infection Solution Guide. American Journal of Infection Control45(6), S103. doi:10.1016/j.ajic.2017.04.165

Klintworth, G., Stafford, J., O’Connor, M., Leong, T., Hamley, L., Watson, K., … Worth, L. J. (2015). Beyond the intensive care unit bundle: Implementation of a successful hospital-wide initiative to reduce central line-associated bloodstream infections. American Journal of Infection Control42(6), 685-687. doi:10.1016/j.ajic.2014.02.026

Leistner, R., Thürnagel, S., Schwab, F., Piening, B., Gastmeier, P., & Geffers, C. (2015). The impact of staffing on central venous catheter-associated bloodstream infections in preterm neonates – results of a nation-wide cohort study in Germany. Antimicrobial Resistance and Infection Control2(1), 11. doi:10.1186/2047-2994-2-11

Ling, M. L., Apisarnthanarak, A., Jaggi, N., Harrington, G., Morikane, K., Thu, L. T., … Lee, C. (2016). APSIC guide for prevention of Central Line-Associated Bloodstream Infections (CLABSI). Antimicrobial Resistance & Infection Control5(1). doi:10.1186/s13756-016-0116-5

Marschall, J. (2010). Current strategies for the prevention and management of central line-associated bloodstream infections. Infection and Drug Resistance, 147. doi:10.2147/idr.s10105

Masse, V., Edmond, M. B., & Diekema, D. J. (2018). Infection prevention strategies for procedures performed outside operating rooms: A conceptual integrated model. American Journal of Infection Control46(1), 94-96. doi:10.1016/j.ajic.2017.07.030

Morrison, T., Raffaele, J., & Brennaman, L. (2017). Impact of personalized report cards on nurses managing central lines. American Journal of Infection Control45(1), 24-28. doi:10.1016/j.ajic.2016.09.020

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O’Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., … Saint, S. (2015). Summary of Recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections. Clinical Infectious Diseases52(9), 1087-1099. doi:10.1093/cid/cir138

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Stone, P. W., Pogorzelska-Maziarz, M., Herzig, C. T., Weiner, L. M., Furuya, E. Y., Dick, A., & Larson, E. (2016). State of infection prevention in US hospitals enrolled in the National Health and Safety Network. American Journal of Infection Control42(2), 94-99. doi:10.1016/j.ajic.2013.10.003

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