1. Running head: CENTRAL LINE PROTOCOL 1
Baylor Scott & White Central Line Maintenance Protocol
Codi Leggett
NURS 411: Evidence-Based Practice for Nurses
May 3, 2016
Abstract

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Baylor Scott & White Health (BSWH) has a central line protocol which provides direction for
providers in how to administer, access, maintain, and flush. These guidelines should be
evidence-based practices, but research should be evaluated to determine if the protocol is up to
date with the evidence. Evidence was found that supports the protocol is following recent
evidence-based practice. However, enforcement is the greatest concern for this protocol because
the criteria is evidence-based, but it cannot prove its effectiveness without proper adherence to
the protocol.
Baylor Scott & White Central Line Maintenance Protocol

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“Seven years of zero central-line-associated bloodstream infections” is what the Sutter
Roseville Medical Center PICC team has achieved after implementing their central line bundle
checklist and protocols (Harnage, 2012). If all facilities could achieve this kind of successful
infection prevention, it would completely change this area of medicine in the future. All hospitals
and healthcare facilities are supposed to have policies and protocols in place to keep the
healthcare providers in line with appropriate practices. A specific protocol from the Baylor Scott
& White Health (BSWH) guidelines was chosen to evaluate and determine if it follows best
practices according to research evidence, especially since this facility strives to use evidence-
based practice (EBP) (2011/2015). The BSWH protocol describes the guidelines for cleaning the
catheter ports, flushing the tubing (how and when), and requirements for changing the dressing
and maintaining the catheters. The following contains a synthesis of the evidence from several
scholarly articles, a summary of the BSWH protocol, and together both will be used to determine
best practice for central line protocols. Additional evidence can be found in Appendix B. It is
important to look at the evidence for the protocol to ensure the facility is using best practices,
and to prevent bloodstream infections which are often caused by lack of adherence to protocols
and best practices. The synthesis of evidence will be used to determine the validity of the
protocol and then compare it to what is used at the BSWH facility to see if it is supported by best
practice evidence. The strength of the evidence will be determined and then recommendations
will be made for practices based on the evidence.
Overview of the Practice Guideline
Baylor Scott & White Health provides nurses and other qualified personnel with
the “Maintaining, Accessing, and Flushing Central Lines Protocol” (BSWH, 2011/2015). The
policy, protocol, and associated charts for this can be found attached in Appendix A (BSWH,

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2011/2015). This protocol provides direction for the best way to perform care of central lines at
the BSWH hospital in College Station, Texas. They provide assessment frequency, how often
dressings need to be changed and which techniques to use. The hospital protocol utilizes a chart
for nurses to easily refer to proper flushing, maintenance, and accessing for each equipment type
(BSWH, 2011/2015). Nurses can use this protocol and tool to implement EBP when caring for
patients that have a central line. The target population is chronically ill patients or patients that
need more long term venous access for their treatment. The goal of this protocol is to reduce
infections by implementing evidence-based practice for the nurses of this facility to use when
caring for central lines (BSWH, 2011/2015). Central lines provide direct access to the blood in
the heart, and preventing infection from developing and spreading systemically is crucial. The
policy superseding this protocol stresses the use of EBP at Baylor Scott & White and references
are provided, however they are not easily accessible because they are formally cited in another
section of the hospital protocol database. It would be useful to have the resources more
accessible in order to check the validity of the sources. This protocol originated in January 2011,
and was last reviewed/revised in May 2015. Although this is recent, new research could have
developed within one year (BSWH, 2011/2015).
Synthesis of the Evidence
In a meta-analysis regarding prevention of central line infections, it was found that
quality improvement interventions reduced the rate of central line infections. Specifically, the
bundle and checklist intervention, along with education, evaluated before and after, showed
significant results for decreasing the rate of central-line associated infections (Blot, Bergs,
Vogelaers, Blot, & Vandijck, 2014). Although each bundle and checklist can be different, most

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included hand hygiene, chlorhexidine skin antiseptics, and sterile barrier precautions, all of
which contributed to the decreased rate overall by implementing all of these to prevent infection.
The meta-analysis is an ideal supporting article for the Central Line Protocol at Baylor
Scott & White Health (BSWH) because they utilize a bundle and checklist system to ensure
adequate protocol, and educate the patient before obtaining informed consent to the procedure
(BSWH, 2011/2015). Forty-one before-and-after studies revealed that bundle and checklist
interventions, along with education decreased the rate of central-line associated infections with
significance of P<.001 vs checklists alone were only P=0.3 (Blot, Bergs, Vogelaers, Blot, &
Vandijck, 2014). The combined multi-angle improvement technique proved a decreased rate
from 1.5 to 0 central line infections per 1000 catheter days (Blot, Bergs, Vogelaers, Blot, &
Vandijck, 2014). This article proves very effective in supporting the BSWH protocol.
A quantitative study discussed the effects of infection control by using a scrub-the-hub
technique or a disinfection cap when caring for central and peripheral IV lines. They revealed
that if only one item was used, the disinfection cap was the most effective in preventing
infection, however, if both techniques were used together, the disinfection rate could
significantly be reduced (DeVries, Mancos, & Valentine, 2014).
The BSWH central line protocol requires use of a disinfection cap on the tubing and
scrubbing the hub before using the line for anything (BSWH, 2011/2015). This is supported by
DeVries, Mancos, and Valentine’s quantitative study that reveals the rate of bloodstream
infections was reduced by 50% in central lines by using a disinfection cap (2014). It is also
suggested that if the two interventions are used together that the reduction in infection rate could
be greater than 50% (DeVries, Mancos, & Valentine, 2014).

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Bloodstream infections have an increased risk when errors occur during the insertion of
the line, according to Barreto and colleagues (2013). They completed a quantitative study to
evaluate a correlation between the number of errors in placing the devices and the rate of
bloodstream infections in patients (Barreto et al., 2013). Errors range from not cleaning
adequately and not wearing gloves, to any action that swayed from the protocol of the facility
being observed (Barreto et al., 2013).
It is crucial to minimize errors when caring for central lines because mistakes can affect
the safety of patients and increase the risk of infections when using central lines. The BSWH
central line protocol requires properly trained professionals and proper technique to be employed
during central line insertion and maintenance (BSWH, 2011/2015). This article supports the
protocol by revealing that the more errors that occurred, the higher the chance of bloodstream
infection occurring with significance (r=0.845 and p=0.000) (Barreto et al., 2013). The use of
correct techniques, education, and experience can help eliminate errors and increased infection
risk.
Even though we hope all nurses and providers follow evidence-based practice, there are
some things that interfere with compliance of guidelines. According to Gurses and colleagues’
qualitative study, five types of ambiguity exist: task, expectation, responsibility, method, and
exception (2008). Additionally, heavy workload, understaffing, disagreement, costs of
implementation, forgetfulness, and lack of supplies all contribute to the increase of infections
and medical errors (Gurses et al., 2008).
Compliance with guidelines also protects the safety of patients and staff. Without it, the
risk of infection increases. A qualitative study revealed that five types of ambiguity (task,
expectation, responsibility, method, and exception) affect compliance with protocols and can

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cause an increase in infection rates (Gurses et al., 2008). This supports the BSWH protocol
because it reinforces the need to follow the protocol itself because when ambiguity affects the
compliance, infection rates increase (BSWH, 2011/2015). Gurses et al. article also provides
insight for the BSWH facility to observe their contributors to non-compliance such as workload,
number of staff, costs, and the amount of supplies to see if they need changes to help protect the
safety of patients (2008).
Since occlusion of an IV catheter can lead to infection, vessel irritation, and embolus, a
quantitative study was completed to determine if the beginning of occlusion in catheters could be
predicted to decrease complications (Wolf et al., 2015). Catheter-resistance monitoring was used
to predict occlusion in catheters, and was found to be capable of predicting possible occlusions
(Wolf et al., 2015). Saline flushes are often used to ensure patency, but by measuring the
pressure, nurses could begin to predict the beginning of an occlusion before infection occurs.
Catheter occlusion can lead to infection, and the BSWH central line protocol provides
specific instructions for flushing techniques and frequency to prevent occlusion and infection
(BSWH. 2011/2015). A quantitative study was performed to determine the predictability of
occlusion using saline flushes and revealed p<0.01 prediction of occlusion within 10 days. The
study supported the BSWH protocol for flushing, but refuted it by displaying the need to add
catheter-resistance monitoring to the protocol as well in addition to flushing before and after use
of any line (Wolf et al., 2015).
Recommendations for Practice
The BSWH central line protocol follows a bundle checklist system for maintaining,
accessing, and flushing central lines. Blot et al. (2014) compares different improvement
interventions, and found that bundles or checklists revealed the largest decrease in infection rate.

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This Level I study (Polit & Beck, 2014, p. 22) provides useful evidence because it utilizes a
systematic review followed by a meta-analysis of multiple articles. It reveals that bundles and
checklists almost always include the major aspects that contribute to decreased infections, which
in this study, resulted in zero catheter infections in 1000 days (Blot, Bergs, Vogelaers, Blot, &
Vandijck, 2014). The evidence supports the checklists used for the BSWH protocol, and should
continue to be used in practice.
Scrubbing the hub or use of a disinfection cap is what is considered appropriate in the
BSWH protocol (2015). DeVries, Mancos, and Valentine (2014) reveal that the disinfection cap
decreased infection rates by 50% which supports the BSWH protocol (2011/2015). However,
this level III, prospective, observational study (Polit & Beck, 2014, p. 23) reveals that the use of
both the disinfection cap and scrubbing the hub would be the most beneficial based on the trial
(DeVries, Mancos, & Valentine, 2014). Although not the strongest level of evidence, the drastic
significance of the results reveal the importance of implementing these two techniques together
which would be the best recommendation for practice.
Errors while administering central lines can greatly affect the risk of infection according
to Barreto et al. (2013). This level IV, longitudinal, prospective study (Polit & Beck, 2014, p. 23)
shows the connection of administration errors and maintenance errors increase infection risk
(Barreto et al., 2013). This supports the BSWH protocol (2011/2015) because it requires
specifically trained personnel to administer central lines, and requires maintenance guidelines to
prevent infection. The best recommendation is to enforce the protocol in place at BSWH.
Another level IV, prospective study (Polit & Beck, 2014, p. 23) revealed that catheter
occlusion can be predicted and prevent the development of a bloodstream infection (Wolf et al.,
2015). The BSWH protocol (2011/2015) contains flushing recommendations to prevent

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occlusion, but it does not measure pressures to predict occlusions (Wolf et al., 2015). This study
supports the BSWH protocol criteria of flushing, but could also be improved by adding pressure
measurements to the flushing protocol.
Gurses et al. (2008) utilized a grounded theory level VII study (Polit & Beck, 2014, p.
48) to evaluate the ambiguity that causes protocols to not be followed and determine the social
influences on protocol adherence. Although this study does not directly support the criteria
within the protocol, it supports the need for the protocol as a whole, and encourages the
recommendation of eliminating ambiguities which interfere with protocol adherence (Gurses et
al., 2008). If the protocol is followed, the risk for infection in central lines will be reduced, and it
is recommended that the facility enforce its protocol that is in place.
Conclusion
These articles are all supporting the Baylor Scott & White Health central line protocol,
and provide evidence that the protocol is following evidenced based practice. Not every criteria
within the protocol is explained in depth with evidence, but these articles validate many of the
important aspects within the protocol. Some of the evidence focuses on ensuring that the
protocol is actually enforced and utilized, because even though many protocols exist, they do not
provide benefits unless they are utilized the way they are written. Having evidence to support the
protocol ensures patients receive care that has demonstrated proven results. Overall, the best
recommendation is to adhere to the protocol that already exists, specifically utilizing the
checklist, the hub disinfection, and the flushing techniques. According to Harnage (2012),
bundles and checklists, if they are evidence-based and are followed as written by providers, can
have the potential to almost completely eradicate central line infections. More research should be

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completed to evaluate the best practice of each specific criteria of the protocol, but overall the
BSWH protocol proves to be following best practice.

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References
Baylor Scott & White Health. (2015). Maintaining, accessing, and flushing central lines protocol.
Central line management (X.1079.3.SW.059). (pp. 1-4). (Original work published 2011)
Blot, K., Bergs, J., Vogelaers, D., Blot, S., & Vandijck, D. (2014). Prevention of central line–
associated bloodstream infections through quality improvement interventions: A
systematic review and meta-analysis. Clinical Infectious Diseases, 59(1), 96-105.
DeVries, M., Mancos, P. S., & Valentine, M. J. (2014). Reducing bloodstream infection risk in
central and peripheral intravenous lines: Initial data on passive intravenous connector
disinfection. Journal of the Association for Vascular Access, 19(2), 87-93 7p.
doi:10.1016/j.java.2014.02.002
Filgueira Gouveia Barreto, A., Yurà Araújo Farias Dias, T., Fernandes Costa, I. K., de Sousa
Martins Melo, G., Elza Oliveira de Mendonça, A., & de Vasconcelos Torres, G. (2013).
Infection of central venous catheter and the non-compliance of protocols in the intensive
care unit. Journal of Nursing UFPE / Revista de Enfermagem UFPE, 7(2), 430-437 8p.
doi:10.5205/reuol.3073-24791-1-LE.0702201314
Gurses, A. P., Seidl, K. L., Vaidya, V., Bochicchio, G., Harris, A. D., Hebden, J., & Xiao, Y.
(2008). Systems ambiguity and guideline compliance: A qualitative study of how
intensive care units follow evidence-based guidelines to reduce healthcare-associated
infections. Quality & Safety in Health Care, 17(5), 351-359.
doi:10.1136/qshc.2006.021709
Harnage, S. (2012). Seven years of zero central-line-associated bloodstream infections. British
Journal Of Nursing, S6-S12 1p.
Polit, D. F., & Beck, C.T. (2014). Essentials of nursing research: Appraising evidence in nursing
practice (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

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Wolf, J., Tang, L., Rubnitz, J. E., Brennan, R. C., Shook, D. R., Stokes, D. C., & ... Flynn, P. M.
(2015). Monitoring central venous catheter resistance to predict imminent occlusion: A
prospective pilot study. Plos ONE, 10(9), 1-15. doi:10.1371/journal.pone.0135904

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Appendix A: Protocol

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Appendix B: Evidence Grid
Citation (APA) Purpose Sample Design Measurement Results/Conclusions Level of
Evidence
Blot, K., Bergs, J.,
Vogelaers, D., Blot, S., &
Vandijck, D. (2014).
Prevention of central
line–associated
bloodstream infections
through quality
improvement
interventions: A
systematic review and
meta-analysis. Clinical
Infectious Diseases,
59(1), 96-105.
Determine the
effects of quality
improvement
interventions for
central lines
reduce
bloodstream
infection rates
based on different
studies and
different
interventions.
N= 584 ICUs
Article samples:
634 screened
75 articles assessed
for eligibility
63 articles in
systematic review
43 studies included
in meta-analysis
Intervention
category and
number of studies:
Education (33),
training (4),
feedback (20),
clinical reminders
(15), bundle (11),
checklist (18),
empowerment to
stop procedure
(10), surveillance
(12), leader
designation (11),
prepackaging (16),
infrastructure
changes (2),
organizational
changes (4)
Systematic review
followed by
random-effects
meta-analysis
(Eligible studies
used before-after,
interrupted time
series (ITS),
controlled before-
after,
nonrandomized
controlled trial,
and randomized
controlled studies)
Before-after and
ITS are preferred
27 questions were
used to evaluate the
validity and power of
each study
the DerSimonian-
Laird
estimator obtained
odds ratios for
rate reductions. The
Higgins I2 test was
predefined to
quantify
heterogeneity (I2 ≤
25% for low, 25% <
I2 < 50% for
moderate,
and I2 ≥ 50% for
high), and funnel
plots assessed
publication
bias; subgroup
analysis through
meta-regression
compared checklist
interventions.
Quality improvement interventions
reduce central-line infection rates.
The infection rate was decreased the
most with bundles or checklist
interventions.
Feedback intervention was the least
improvement rate, however
significant rate reduction in
infection still occurred.
Further research should be done to
determine requirements of
successful adaptation of the
interventions.
Level I

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DeVries, M., Mancos, P.
S., & Valentine, M. J.
(2014). Reducing
bloodstream infection risk
in central and peripheral
intravenous lines: Initial
data on passive
intravenous connector
disinfection. Journal of
the Association for
Vascular Access, 19(2),
87-93 7p.
doi:10.1016/j.java.2014.0
2.002
Determine if the
use of a
disinfection cap
decreases the rate
of bloodstream
infections in
central/PICC and
peripheral lines.
3 intensive care
units for a 3-month
span (all patients
with a
central/PICC or
peripheral line)
Prospective
observational
study that is not
randomized
Bloodstream
infection rate was
tracked for the 3
months and no
infections occurred
during the 3 month
trial. Pre-intervention
and post-intervention
rates were compared
later to determine the
reduction rate with
the intervention.
The combined reduction rate for
central lines and peripheral IV lines
was decreased by 50.0%.
Use of the disinfection cap offers
protections that “scrub-the-hub”
cannot provide alone.
The disinfection cap used with the
“scrub-the hub” technique together
shows a significant bloodstream
infection rate in central lines and
peripheral lines (P < .000001).
Level III
Filgueira Gouveia
Barreto, A., YurÃ
Araújo Farias Dias, T.,
Fernandes Costa, I. K., de
Sousa Martins Melo, G.,
Elza Oliveira de
Mendonça, A., & de
Vasconcelos Torres, G.
(2013). Infection of
central venous catheter
and the non-compliance
of protocols in the
intensive care unit.
Journal of Nursing UFPE
/ Revista de Enfermagem
UFPE, 7(2), 430-437 8p.
doi:10.5205/reuol.3073-
24791-1-LE.0702201314
Determine if
central venous
catheter infections
are being caused
by non-
compliance of
staff with protocol
of insertion or
maintenance of
the line.
N= 31 patients
undergoing central
venous catheter
insertion
Longitudinal,
prospective study
Researchers observed
insertion and
maintenance of
central venous
catheters and
considered errors that
occurred for both
insertion and
maintenance.
to compare the
mean scores of errors
in the procedure of
inserting and
maintaining the
catheter, and
the Spearman
Correlation test (r
<0.50 = poor,
0.50 ≤ r ≥ 0, 74 =
moderate, r ≥ 0.75 =
strong)
The higher number of errors that
occur during the insertion and
maintenance of central catheters
revealed increased risk for infection.
(2-9 errors resulted in infection & 0-
5 errors did not result in infection)
-risk of
infection at the insertion time:
strong and significant
(r = 0.845 p = 0.000)
-risk of infection in
Maintenance: moderate and
significant
(r = 0.551 p = 0.001)
Level IV

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Gurses, A. P., Seidl, K.
L., Vaidya, V.,
Bochicchio, G., Harris, A.
D., Hebden, J., & Xiao,
Y. (2008). Systems
ambiguity and guideline
compliance: A qualitative
study of how intensive
care units follow
evidence-based guidelines
to reduce healthcare-
associated infections.
Quality & Safety in
Health Care, 17(5), 351-
359.
doi:10.1136/qshc.2006.02
1709
Evaluate if
evidence-based
practices are
being followed by
health care staff to
prevent infections
caused by central
venous catheters,
ventilator-assisted
pneumonia,
surgical site
infections, and
catheter
associated UTI.
What causes
protocol to not be
followed by staff.
N=20
Sample of 3
physicians, 2
residents, 6 nurses,
3 quality
improvement
coordinators, 2
infection control
practitioners, 2
respiratory
therapists, and 2
pharmacists
Grounded Theory 20 semistructured
interviews
(14-66 min
interviews)
Systems ambiguity plays a major
role in non-compliance of evidence-
based guidelines.
Things that contribute to non-
compliance are heavy workload,
understaffed, disagreement, costs of
implementation, forgetfulness, lack
of supplies and equipment.
There are 5 types of ambiguity that
exist: task, expectation,
responsibility, method, and
exception. All of which contribute
to hospital acquired infections,
medical errors and an obstacle for
learning.
Level VII
Wolf, J., Tang, L.,
Rubnitz, J. E., Brennan,
R. C., Shook, D. R.,
Stokes, D. C., & ... Flynn,
P. M. (2015). Monitoring
central venous catheter
resistance to predict
imminent occlusion: A
prospective pilot study.
Plos ONE, 10(9), 1-15.
doi:10.1371/journal.pone.
0135904
Determine the
feasibility,
acceptability, and
efficacy of
monitoring central
venous catheters
for signs of
occlusion
(resistance).
n=10 pediatric
patients over 113
central-resistance
monitoring visits
Prospective study Catheter-resistance
monitoring was
performed weekly for
up to 12 weeks.
Normal saline was
injected while inline
pressure rates were
measured using a
syringe pump with an
incorporated
pressure-sensing
inducer
Catheter occlusion occurred
frequently and CRM was helpful in
predicting these event.
Some analysis showed p<0.01
prediction of occlusion within 10
days; another predicted p=0.01
prediction of occlusion within 10
days.
The sensitivity and specificity are
reasonable but imperfect.
Level IV

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