Running head TITLE IN ALL CAPS .docx

Running head: TITLE IN ALL CAPS
1
TITLE IN ALL CAPS
4
Title of Paper
Student Name
Grand Canyon University
Title of Paper with no bold (no more than 75 words)
Introduce your main thesis here. [introduction to your paper
paragraph].
Background (no more than 125 words)
This paragraph addresses why the proposed work is important in

the field. In this section, provide the status quo of the relevant
work field and identify a gap in knowledge or activities that
must be filled to move the field forward.
Problem Statement (no more than 125 words)
Sufficient details should be given in this discussion (1) to make
clear what the research problem is and exactly what has been
accomplished; (2) to give evidence of your own competence in
the field; and (3) to show why the previous work needs to be
continued.
Purpose of the Change Proposal (no more than 125 words)
Place a testable, focused, clear, declarative statement of
relationships between variables based on previous
observations.
PICOT
PICO (T) components and question needs to be placed here.
Literature Search Strategy (no more than 75 words)
Here is the information you might want to include when
describing your literature search process: Databases used,
Search terms used, Details of your search equations, Selection
or exclusion criteria, Additional search methods, Number of
results found, Final number of documents used and Types of
documents used.
Evaluation of Literature (no more than 200 words)
Literature reviews should be selective and critical. Reviewers
do not want to read through a voluminous working
bibliography; they want to know the pertinent works and your
evaluation of them. Discussions of work done by others should
therefore lead the reader to a clear impression of how you will
be building upon what has already been done and how your
work differs from theirs. It is important to establish what is
original in your approach (innovative), what circumstances have
changed since related work was done, or what is unique about
the time and place of the proposed research.
Applicable Change or Nursing Theory Utilized (no more than
150 words)
To write this paragraph you must choose a Nursing theory

and/or Framework. After choosing your theory and/or
framework you will talk to how it Provides a structure for the
study, Provides the rationale for the predictions of the
relationships between the variables, GUIDEs and directs the
study and Helps make sense of meaning of the study
(meaningful interpretation).
Proposed Implementation Plan with Outcome Measures (no
more than 200 words)
Implementation plan is a guide for developing the program, tool
for planning the piloting of the program and provides a timeline
of actions or activities. A concise, easy-to-read overview of
goals, strategies, objectives, outcome measures, timeline, and
responsible parties.
Identification of Potential Barrier to Plan Implementation and a
Discussion of How these could be Overcome (no more than 200
words)
Identification of potential barriers to plan implementation.
Overcoming Barriers (no more than 150 words)
Discussion on how these barriers can be overcome.
Conclusion (no more than 75 words)
Your conclusion should restate the main idea of your paper or
thesis statement, summarize your paper, and leave an interesting
final impression.
References

Appendix Section (please review guidelines for APA 6th edition
for appendix section)
In the appendix section you will have your Developed tools
necessary to educate project participants and Developed
assessment tool(s) necessary to evaluate project outcomes.
(powerpoint educational module, surveys, pamphlet, etc.)
To help you embed your developed tools view the link below:
https://support.office.com/en-us/article/Insert-an-object-in-
Word-or-Outlook-8fc1ea53-0e01-4603-a4cf-98c49b6ea3f5
Journal Article summay 7
by Ravinder Kommerelli
Submission date: 29-Jul-2019 11:05PM (UTC-0400)
Submission ID: 1156121420
File name:
12686_Ravinder_Kommerelli_Journal_Article_summay_7_1500
889_76629558.doc (48K)
Word count: 691

Character count: 4490
48%
SIMILARITY INDEX
37%
INTERNET SOURCES
0%
PUBLICATIONS
31%
STUDENT PAPERS
1 12%
2 8%
3 6%
4 3%
5 3%
6 3%
7 3%
8 3%

ORIGINALITY REPORT
PRIMARY SOURCES
pdfs.semanticscholar.org
Internet Source
Submitted to Northern Melbourne Institute of
TAFE
Student Paper
www.steveseager.com
Internet Source
smallbusiness.chron.com
Internet Source
Submitted to California State University,
Monterey Bay
Student Paper
Submitted to Barry University
Student Paper
Submitted to Corinthian Colleges
Student Paper
Submitted to Southern New Hampshire
University - Continuing Education
Student Paper
9 3%

10 1%
11 1%
12 1%
Exclude quotes Off
Exclude bibliography Off
Exclude matches Off
Submitted to University of Nottingham
Student Paper
Submitted to University of Greenwich
Student Paper
network.bepress.com
Internet Source
Submitted to University of Strathclyde
Student Paper
PAGE 1
PAGE 2
PAGE 3
PAGE 4
PAGE 5
Journal Article summay 7by Ravinder KommerelliJournal
Article summay 7ORIGINALITY REPORTPRIMARY

SOURCESJournal Article summay 7
Journal Article Summary 6
by Ravinder Kommerelli
Submission date: 29-Jul-2019 09:04AM (UTC-0400)
Submission ID: 1155946380
File name:
12686_Ravinder_Kommerelli_Journal_Article_Summary_6_150
0881_2001715198.doc (48K)
Word count: 591
Character count: 3821
37%
SIMILARITY INDEX
23%
INTERNET SOURCES
2%
PUBLICATIONS
34%
STUDENT PAPERS

1 7%
2 5%
3 4%
4 4%
5 3%
6 3%
7 3%
8 3%
9
ORIGINALITY REPORT
PRIMARY SOURCES
Submitted to Southern New Hampshire
University - Continuing Education
Student Paper
Submitted to University of East London
Student Paper
Submitted to Bridgepoint Education
Student Paper
Submitted to Saint Leo University
Student Paper
smallbusiness.chron.com
Internet Source
Submitted to New Jersey City University
Student Paper

Submitted to La Trobe University
Student Paper
fisherpub.sjfc.edu
Internet Source
Submitted to University of Bedfordshire
2%
10 1%
11 1%
12 1%
Exclude quotes Off
Exclude bibliography Off
Exclude matches Off
Student Paper
Submitted to Intercollege
Student Paper
Submitted to National American University
Student Paper
Submitted to Macquarie University
Student Paper
PAGE 1

Sp. This word is misspelled. Use a dictionary or spellchecker
when you proofread your work.
PAGE 3
PAGE 4
Journal Article Summary 6by Ravinder KommerelliJournal
Article Summary 6ORIGINALITY REPORTPRIMARY
SOURCESJournal Article Summary 6
Running head: TITLE IN ALL CAPS
1
TITLE IN ALL CAPS
4
Title of Paper
Student Name
Grand Canyon University

Title of Paper with no bold (no more than 75 words)
Introduce your main thesis here. [introduction to your paper
paragraph].
Background (no more than 125 words)
This paragraph addresses why the proposed work is important in
the field. In this section, provide the status quo of the relevant
work field and identify a gap in knowledge or activities that
must be filled to move the field forward.
Problem Statement (no more than 125 words)
Sufficient details should be given in this discussion (1) to make
clear what the research problem is and exactly what has been
accomplished; (2) to give evidence of your own competence in
the field; and (3) to show why the previous work needs to be
continued.
Purpose of the Change Proposal (no more than 125 words)
Place a testable, focused, clear, declarative statement of
relationships between variables based on previous
observations.
PICOT
PICO (T) components and question needs to be placed here.
Literature Search Strategy (no more than 75 words)
Here is the information you might want to include when
describing your literature search process: Databases used,
Search terms used, Details of your search equations, Selection
or exclusion criteria, Additional search methods, Number of
results found, Final number of documents used and Types of
documents used.
Evaluation of Literature (no more than 200 words)
Literature reviews should be selective and critical. Reviewers
do not want to read through a voluminous working

bibliography; they want to know the pertinent works and your
evaluation of them. Discussions of work done by others should
therefore lead the reader to a clear impression of how you will
be building upon what has already been done and how your
work differs from theirs. It is important to establish what is
original in your approach (innovative), what circumstances have
changed since related work was done, or what is unique about
the time and place of the proposed research.
Applicable Change or Nursing Theory Utilized (no more than
150 words)
To write this paragraph you must choose a Nursing theory
and/or Framework. After choosing your theory and/or
framework you will talk to how it Provides a structure for the
study, Provides the rationale for the predictions of the
relationships between the variables, GUIDEs and directs the
study and Helps make sense of meaning of the study
(meaningful interpretation).
Proposed Implementation Plan with Outcome Measures (no
more than 200 words)
Implementation plan is a guide for developing the program, tool
for planning the piloting of the program and provides a timeline
of actions or activities. A concise, easy-to-read overview of
goals, strategies, objectives, outcome measures, timeline, and
responsible parties.
Identification of Potential Barrier to Plan Implementation and a
Discussion of How these could be Overcome (no more than 200
words)
Identification of potential barriers to plan implementation.
Overcoming Barriers (no more than 150 words)
Discussion on how these barriers can be overcome.
Conclusion (no more than 75 words)
Your conclusion should restate the main idea of your paper or
thesis statement, summarize your paper, and leave an interesting
final impression.
References

Appendix Section (please review guidelines for APA 6th edition
for appendix section)
In the appendix section you will have your Developed tools
necessary to educate project participants and Developed
assessment tool(s) necessary to evaluate project outcomes.
(powerpoint educational module, surveys, pamphlet, etc.)
To help you embed your developed tools view the link below:
https://support.office.com/en-us/article/Insert-an-object-in-
Word-or-Outlook-8fc1ea53-0e01-4603-a4cf-98c49b6ea3f5

Articles
Fronzo, C. (2017). Approaches for standardising best practice to
reduce CRBSIs and CLABSIs. British Journal of Nursing,
26(19), S32-S35.
Humphrey, J. S. (2015). Improving Registered Nurses'
Knowledge of Evidence-Based Practice Guidelines to Decrease
the Incidence of Central Line-Associated Bloodstream
Infections: An Educational Intervention. Journal of the
Association for Vascular Access, 20(3), 143-149.
Infobase,, & Wellness Network (Firm). (2018). Removal of
Your Central Venous Catheter for Hemodialysis. (Films on
Demand.)
Marschall, J., Mermel, L. A., Fakih, M., Hadaway, L., Kallen,
A., O’Grady, N. P., ... & Yokoe, D. S. (2014). Strategies to
prevent central line-associated bloodstream infections in acute
care hospitals: 2014 update. Infection Control & Hospital
Epidemiology, 35(S2), S89-S107.
McAlearney, A. S., & Hefner, J. L. (2014). Facilitating central
line–associated bloodstream infection prevention: a qualitative
study comparing perspectives of infection control professionals
and frontline staff. American journal of infection control,
42(10), S216-S222.
O’Neill, L., Park, S. H., & Rosinia, F. (2018). The role of the
built environment and private rooms for reducing central line-
associated bloodstream infections. PloS one, 13(7), e0201002.
Reyes, D. C. V., Bloomer, M., & Morphet, J. (2017). Prevention
of central venous line associated bloodstream infections in adult
intensive care units: A systematic review. Intensive and Critical
Care Nursing, 43, 12-22.
Weingart, S. N., Hsieh, C., Lane, S., & Cleary, A. M. (2014).
Standardizing central venous catheter care by using
observations from patients with cancer. Clinical journal of
oncology nursing, 18(3).

Running head: PICOT Statement: CLABSI 1
PICOT Statement: CLABSI4
Running head and header written incorrectly
PICOT Statement: CLABS
I
Adrian Christian
Prof. Samantha Deck
NRS- 490
6/21/2019
PICOT Statement: CLABSI
Nursing Practice Problem
Central Line-associated Bloodstream infections (CLABSI) is an
essential lab affirmed circulation system disease in a patient
with a central line at the period of (or within 48-hours
preceding) the beginning of signs, and the condition isn't

identified with a disease from another site. CLABSI happen
when a central line isn't placed well or not kept clean. This
enables the central line to turn into a path for germs to enter the
body and cause dangerous infections in the blood (Fronzo,
2017). CLABSIs result in a high mortality rate every year and
billions of dollars in added expenses to the U.S. healthcare
sector, yet these diseases are the preventable kind of medical
services related to contaminations. CDC has given guidelines
and tools to the healthcare sector to help end
CLABSIs.Comment by samantha deck: Passive voice, please
rewrite sentences like thisComment by samantha deck: Unclear
antecedent; unclear who or what this is referring to. Please
rewrite sentences like this.
PICOT Statement
P- Adult patients in the cardiovascular ICU
I- Use ofimplementation of CLABSI bundle protocol
C- No protocol, individual basisstandard protocol
O- Decreased rate of CLABSIsreduce CLABSI rates
T- during ICU staywithin 3 months
For adult patients in the cardiovascular ICU, doe shte
implementation of a CLABSI bundle protocol compared to the
standard protocol reduce the rates of central line associated
bloodstream infections (CLABSI) within 3 months?
CLABSI is normal among grown-up patients in the Intensive
Care Units. The disease draws in a great deal of care since it is
costly to deal with, and as a result of its life-threatening nature
(Reyes, Bloomer & Morphet, 2017). The rate of CLABSI has, to
a great extent, decreased over the ongoing years, an outcome
that has been credited to the diminished recurrence of getting to
the central line. .
Nonetheless, around 30,000 cases are as yet enlisted in
Intensive Care Units yearly. It has been resolved that the
explanation behind the high claims is the increased risk and
presentation in the Pediatric Intensive Care Units because of
regular access to the central lines. By and large, a medical
caretaker can get to the central line near multiple times within a

shift of 12 hours; however, this number can change contingent
upon the specialist's directions (Humphrey, 2015). The meds
that are being managed additionally affect the quantity of
access.
In as much as CLABSI is perilous and ought not to be messed
with, it is imperative to comprehend that using evidence-based
fundamental practices, it is preventable (Reyes et al., 2017).
Central Venous Catheter Insertion is a proof based strategy for
mediation that includes a few components that work together to
achieve an aggregate improvement in the counteractive action of
CLABSI. These components incorporate observing hand
cleanliness before insertion, utilizing sterile gears, and sterile
gloves, a large, sterilized body wrap on the patient, a facemask,
and a cap. It likewise incorporates proper cleaning of the central
line by rubbing the center point with a 70% Isopropyl liquor
swab in circular movements for as long as 30 seconds each time
the central line is gotten to by a medical caretaker. The
connections and lines that are in contact with the central lines
ought to dependably be kept clean (Marschall et al., 2014). A
day by day line survey must be directed for the most punctual
expulsion on the off chance that it isn't essential.
Taking everything into account, from the above discussion, it is,
in this manner, consistent with to state that the use of CVC what
is CVC? Make sure to spell the first instance of abbreviations
out insertion pack will reduce the risk of CLABSI.Comment by
samantha deck: What is the above discussion. Make sure to be
precise in your wording.
References written incorrectly

Fronzo, C. (2017). Approaches for standardising best practice to
reduce CRBSIs and CLABSIs. British Journal of Nursing,
26(19), S32-S35. Missing doi
Humphrey, J. S. (2015). Improving Registered Nurses'
Knowledge of Evidence-Based Practice Guidelines to Decrease
the Incidence of Central Line-Associated Bloodstream
Infections: An Educational Intervention. Journal of the
Association for Vascular Access, 20(3), 143-149. Missing doi
Infobase,, & Wellness Network (Firm). (2018). Removal of
Your Central Venous Catheter for Hemodialysis. (Films on
Demand.)
Marschall, J., Mermel, L. A., Fakih, M., Hadaway, L., Kallen,
A., O’Grady, N. P., ... & Yokoe, D. S. (2014). Strategies to
prevent central line-associated bloodstream infections in acute
care hospitals: 2014 update. Infection Control & Hospital
Epidemiology, 35(S2), S89-S107.
McAlearney, A. S., & Hefner, J. L. (2014). Facilitating central
line–associated bloodstream infection prevention: a qualitative
study comparing perspectives of infection control professionals
and frontline staff. American journal of infection control,
42(10), S216-S222.
O’Neill, L., Park, S. H., & Rosinia, F. (2018). The role of the
built environment and private rooms for reducing central line-
associated bloodstream infections. PloS one, 13(7), e0201002.
Reyes, D. C. V., Bloomer, M., & Morphet, J. (2017). Prevention
of central venous line associated bloodstream infections in adult
intensive care units: A systematic review. Intensive and Critical
Care Nursing, 43, 12-22.
Weingart, S. N., Hsieh, C., Lane, S., & Cleary, A. M. (2014).
Standardizing central venous catheter care by using
observations from patients with cancer. Clinical journal of
oncology nursing, 18(3).
Clinical Journal of Oncology Nursing • Volume 18, Number 3

• Standardizing Central Venous Catheter Care 321
Saul N. Weingart, MD, PhD, Candace Hsieh, RN, Sharon Lane,
RN, MPH, and Angela M. Cleary, RN, MSN
To understand the vulnerability of patients with cancer to
central line-associated bloodstream
infections related to tunneled central venous catheters (CVCs),
patients were asked to describe
their line care at home and in clinic and to characterize their
knowledge and experience manag-
ing CVCs. Forty-five adult patients with cancer were recruited
to participate. Patients were inter-
viewed about the type of line, duration of use, and observations
of variations in line care. They
also were asked about differences between line care at home and
in the clinic, precautions taken
when bathing, and their education regarding line care.
Demographic information and primary
cancer diagnosis were taken from the patients’ medical records.
Patients with hematologic and
gastrointestinal malignancies were heavily represented. The
majority had tunneled catheters with
subcutaneous implanted ports. Participants identified variations
in practice among nurses who cared for them. Although
many participants expressed confidence in their knowledge of
line care, some were uncertain about what to do if the
dressing became loose or wet, or how to recognize an infection.
Patients seemed to be astute observers of their own care
and offered insights into practice variation. Their observations
show that CVC care practices should be standardized, and
educational interventions should be created to address patients’
knowledge deficits.
Saul N. Weingart, MD, PhD, is the chief medical officer at

Tufts Medical Center in Boston, MA; and Candace Hsieh, RN,
is an infection control practitioner, Sharon
Lane, RN, MPH, is the senior director of the Center for Patient
Safety, and Angela M. Cleary, RN, MSN, is a program manager
in the Center for Patient Safety, all
at the Dana-Farber Cancer Institute in Boston. The authors take
full responsibility for the content of the article. The authors did
not receive honoraria for this
work. The content of this article has been reviewed by
independent peer reviewers to ensure that it is balanced,
objective, and free from commercial bias. No
financial relationships relevant to the content of this article
have been disclosed by the authors, planners, independent peer
reviewers, or editorial staff. Mention
of specific products and opinions related to those products do
not indicate or imply endorsement by the Clinical Journal of
Oncology Nursing or the Oncology
Nursing Society. Weingart can be reached at [email protected],
with copy to editor at [email protected] (Submitted April 2013.
Revision
submitted September 2013. Accepted for publication September
16, 2013.)
Key words: central venous catheter; central line-associated
bloodstream infection; practice variation; patient and family
engagement; quality improvement
Digital Object Identifier: 10.1188/14.CJON.321-326
n Journal Club Article
Standardizing Central Venous Catheter Care
by Using Observations From Patients With Cancer
© Robert Byron/Hemera/Thinkstock

C
entral line-associated bloodstream infections
(CLABSIs) can cause significant avoidable morbid-
ity and mortality. Estimates of the costs attributed
to CLABSIs range from $5,734–$22,939 (Centers for
Disease Control and Prevention [CDC], 2011; Scott,
2009). Although an established body of research exists on the
prevention of CLABSIs in the intensive care unit (Pronovost
et al., 2006, 2010), less data were reported about measures to
prevent CLABSIs in patients with cancer treated in ambulatory
settings (Laura et al., 2000; Mermel et al., 2009; O’Grady et al.,
2011; Wolf et al., 2008). A guideline from the American
Society
of Clinical Oncology called for additional research on critical
aspects of central venous catheter (CVC) care for patients with
cancer (Schiffer et al., 2013).
Several factors distinguish the infection risk associated with
CVCs among ambulatory patients with cancer from that of the
general medicine population (Mollee et al., 2011; Tomlinson et
al., 2011). Line care in patients with cancer is usually provided
in the clinic and at home, creating shared responsibility for the
use of safe practices and monitoring for infections. Patients
with cancer undergoing chemotherapy often experience bone
marrow suppression and are susceptible to infection from trans-
located intestinal flora and opportunistic organisms. Although
catheter-related infections among inpatients are exquisitely
sensitive to line placement technique, long-term CVCs are usu-
ally placed in the operating room or an interventional radiology
suite for patients with cancer. As a result, product selection and
line maintenance are critical targets for preventing infection
(Schiffer et al., 2013).
To understand the vulnerability of adult ambulatory patients

with cancer to CLABSIs and to identify potential improvement
opportunities, the authors of the current article surveyed pa-
tients at a comprehensive cancer center. The authors hypoth-
esized that patients were potentially astute observers; were
© Oncology Nursing Society. Unauthorized reproduction, in
part or in whole, is strictly prohibited. For permission to
photocopy, post online, reprint, adapt,
or otherwise reuse any or all content from this article, e-mail
[email protected] To purchase high-quality reprints, e-mail
[email protected]
322 June 2014 • Volume 18, Number 3 • Clinical Journal of
Oncology Nursing
capable of describing variation in line care practice in the clinic
and at home; and could articulate their understanding of proper
central line care, their behavior under certain circumstances,
and their ability to recognize signs of infection.
Methods
Setting and Sample
Dana-Farber Cancer Institute, a Boston-based comprehensive
cancer center that serves adult and pediatric patients with solid
tumors and hematologic malignancies, was the study site. In
2012, more than 348,000 clinic and infusion visits occurred
with 319 nurses and 407 faculty physicians. Adult patients with
long-term CVCs who were treated on two chemotherapy infu-
sion units from July to August 2012 were identified. A research
assistant approached the clinical nurse coordinators on each unit
every day for assistance identifying patients who were suitable

for interview. Exclusion criteria included inability to commu-
nicate in English, anxiety or emotional upset, or being asleep.
Six of 53 potential participants were excluded. Of the re-
maining 47 patients, 45 agreed to participate after the research
assistant described the purpose of the study and length of the
interview. Although the project was conducted as an improve-
ment initiative rather than a research study, the authors were
careful to advise patients that participation was voluntary, that
information they provided would not be shared with their care
team without the patient’s permission, and that they could end
the interview at any time. Interviews varied in length from 5–30
minutes. Patients’ responses were recorded manually and then
entered into an electronic spreadsheet for analysis.
Instrument Development
Because the authors were unable to identify a suitable survey
tool, an instrument was developed for eliciting information
about CVC care from the patient’s perspective. The instrument
was informed by a review of the literature and meetings with
frontline nurses, infection control practitioners, and patient
safety experts. Infection control practitioners and patient safety
experts reviewed the instrument for face validity and pilot
tested it on the study units. It used a semistructured format
with follow-up prompts.
The survey queried patients about the type of line, duration of
use, problems encountered, and observations about variations in
line care. It asked patients to characterize differences between
line care at home and in the clinic, and precautions taken when
showering or bathing at home. It also asked patients to describe
how they were educated about the care of their central line and
to assess its adequacy. The patients rated their confidence in
car-
ing for the line and their knowledge about what to do if the

dress-
ing became loose or wet, and they were asked to describe signs
of
infection. The authors also abstracted information from medical
records (e.g., age, gender, insurance, primary cancer diagnosis).
Data Analysis
The authors tabulated social, demographic, and clinical char-
acteristics. Members of the project team reviewed the survey
responses and categorized them thematically. Certain questions
were inapplicable to particular patients, depending on the type
of line they used. Patients’ responses were tabulated, and illus-
trative, verbatim comments were selected by category.
Results
Patient Characteristics
The median age of the participants was 50–59 years (see
Table 1). More men than women participated in the study,
and the majority had private insurance. The cohort consisted
primarily of patients with hematologic and gastrointestinal
malignancies, reflecting the composition of the clinical unit
where the project was conducted. Thirty-six patients had
surgically implanted catheters with subcutaneous implanted
ports (i.e., port-a-cath), including 13 whose catheters were ac-
cessed for home treatment or supportive care. The remainder
(n = 9) had either surgically implanted cuffed tunneled CVCs
(i.e., Hickman line) or peripherally inserted central catheters
(PICC). Fourteen patients had a previous central line for can-
cer treatment.
TABLE 1. Sample Characteristics (N = 45)
Characteristic n

Age (years)
Less than 40 8
40–49 7
50–59 11
60–69 14
70 or greater 5
Gender
Male 26
Female 19
Insurance type
Private 32
Medicare 10
Medicaid or self-pay 2
Government 1
Disease type
Lymphoma 14
Colorectal 9
Leukemia 6
Pancreatic 5
Myeloma 5
Gastric, esophageal, or biliary tract 3
Brain tumor 1
Myelodysplasia 1
Other 1
Type of central venous catheter
Port-a-cath with no home access 23
Port-a-cath with home access 13
Hickman 6
Peripherally inserted central catheter 3
Number of months since line placement

0–2 12
3–6 12
7–12 9
13–24 4
25 or greater 8
Previous central line
No 31
Yes 14
Practice Variation and Concerns
Most patients observed more similarities than differences
in the way that clinicians cared for their central line. A patient
with a port-a-cath said, “I wouldn’t say that they were all
identi-
cal to each other, but ultimately they all cover the same require-
ments: flushing it, cleaning it, putting the needle in.” Another
patient with a port-a-cath said, “I’ve only had it done a couple
of
times, but it seems pretty much the same. One [provider] might
be a bit slower and another one a bit faster.”
However, 13 of the 45 respondents noted differences in how
the clinician cleaned the hub, their familiarity with the device,
their care in checking the location of the catheter, the use of
dated labels on the line, the degree of care used to avoid hurt-
ing the patient, and staff members’ occasional frustration when
the line did not work properly (see Table 2). One patient with
a Hickman line said,

There are different techniques in the lab around how they
clean it. Some people are very particular about keeping it
clean, and others wipe it off very quickly. Other than how
people clean and prepare it, everyone else sets it up the same.
A patient who had a port-a-cath with a home infusion pump
said,
Today I had someone who cleaned it really well. She really
got right in there. She put this sticker [with initials on it,
placed just below the clamp] on too. See, [the neighboring
patient with a port-a-cath] doesn’t have the sticker. Other
times, people don’t clean it so well.
A minority of patients said that clinic or homecare staff cared
for the line in a way that concerned them. Seven respondents
noted a concern, including failure to clean or flush the line ap-
propriately, failure to allow alcohol to dry, failure to use ethyl
chloride topical anesthetic, pain, or concern about staff
members’
ability to get the catheter to work. A patient with a Hickman
line
said,
It’s just some nurses that I’m not used to don’t scrub the
cap properly, or [use mask and glove] when changing the
dressing. Some scrub it hard, but others just give it a quick
wipe. I like it scrubbed hard. I mean, it goes straight to my
heart. Probably, like, a quarter don’t do it properly.
A patient with a port-a-cath said,
This was early on, maybe six months into it, the nurse for-
got to flush it and I picked up on it. I usually get the smell
and taste of it in my mouth, and that time I didn’t have it,
so I asked her if she’d flushed it and she said she hadn’t. She

fixed it up. That was one incident early on.
Another patient with a port-a-cath said,
One time I didn’t have the [ethyl chloride] spray. He said
he didn’t do it that way. He had his reasons, and others
have theirs. He said “I don’t use the spray.” I think it was
because it exposes everyone in the room; it stays in the
air for a while.
A patient with a port-a-cath said, “Oddly enough, there’s one
person in the lab that never seems to be able to get it to work.
I don’t know their name, and even if I did I wouldn’t tell you. It
could just be chance.”
TABLE 2. Survey Responses and Common
Affirmative Responses (N = 45)
Questions and Responses n
Have you noticed that different people care for the line
differently?
Yes 13
No 25
No response or not applicable 7
• Some are quicker or do not clean the catheter as thoroughly.
• Some are slower and very careful about keeping it clean.
• Some are more experienced and try harder to get it to work.
• Sometimes it hurts more or staff worry about hurting you.
Have you ever noticed anything about the way staff
cared for your line that you were concerned about or
thought was unusual?
Yes 7

No 38
How did you learn about what to do at home?
Some kind of teaching 13
Was not taught 7
• Nurse demonstrated how to do it.
• Written material
• Nurse demonstrated, and patient repeated.
• Patient taught partner(s) or family member(s).
If the dressing became loose or open on one side before
it was scheduled to be changed, what would you do?
Would do something 21
• Call the center.
• Put tape on it.
• Depends on the timing of next scheduled appointment
• Depends on how open it was
• Call the homecare company.
• Go to the cancer center.
What do you do when showering or bathing at home?
Use something to cover it. 16
Do not shower or bathe. 6
Try to avoid it or wash around it. 4
Do you know what symptoms might be present if your
line was infected?
Yes 31
No 13
• Fever

• Redness
• Pain, discomfort, or irritation
• Swelling
• Drainage or leakage
• Low energy, losing energy, or brain stops functioning
What do you find is the most difficult part about caring
for your line or having a line?
At least one problem 28
No problems 17
• Sleeping
• Getting up and forgetting that it is attached
• Showering or bathing
• Getting bumped by young children
• Dislike the look of it
• Keeping it clean and remembering to flush it
Note. Respondents were allowed to choose more than one
answer.
Oncology Nursing
Patient Education
Patients described how they were educated about the care of
their central line and assessed the adequacy of the education.
Nineteen participants recalled learning what to do to care for
the line at home from care providers at the cancer center, dur-
ing a hospitalization, from a homecare provider, or from another
source. Thirteen patients described the methods of instruction,
including nurse demonstration, use of written materials, the
patient teaching other family members after a nurse demonstra-

tion, and using a video. Multiple modalities often were
employed.
A patient with a Hickman line said,
They instructed us a bit before we went home. They told
us not to get it wet, and a bit on the technique how to flush
it. Home care also showed [my family] the technical part
of how to flush it.
One patient who had a port-a-cath with a home infusion
pump said,
The first three times, I had it done here. The first time, they
did it. Then I did part of it. Then I did all of it, with the nurse
watching. They send you home with a sheet of paper with
all the steps to do.
Most patients felt that the training was sufficient, but two
respondents said that they were cautious at first. One of those
patients with a Hickman line said, “Yeah, I mean, the first time
was sketchy. You feel like you’re not doing it right, but you
figure
it out.” Another cautious patient who had a port-a-cath with a
home infusion pump said, “They walked through it with me.
The first time, I was a little slow. I don’t think we were
terrified;
we were cautious. If there had been any sort of complications,
we’d have come in.”
To assess the adequacy of teaching, the authors asked patients
what they would do in certain scenarios (e.g., if the dressing
became loose, if it became wet, if they suspected a line infec-
tion). If the dressing became loose or open before a scheduled
change, the majority of respondents said that they would call
or visit the cancer center, a primary care physician, a homecare

company, or a local hospital. Others said they would assess the
situation or use tape or Tegaderm™. One patient with a port-a-
cath said “I’d probably just tape it up myself, just to make sure
that the port was secure. I’m not grossed out by it.” All of those
responses were judged to be appropriate.
Many had experience with washing or bathing at home. Many
were careful not to wash near the catheter, to avoid showering
or bathing while the port was accessed, or to use plastic wrap
to protect the area. Few had experienced a wet dressing, but
many expressed confidence in their ability to deal with this
scenario. A patient with a PICC line said, “You’d have to
change
it. We have a dressing kit at home. I think I could do it if I had
to.” However, others expressed some apprehension. A patient
who had a port-a-cath with a home infusion pump said, “To be
totally honest, I don’t know. I’d probably panic.”
A majority of patients knew the symptoms that may manifest
if a line were infected (e.g., fever, redness, pain, swelling).
However, 13 patients were unaware of symptoms that would
signal infection. One patient with a port-a-cath said, “I don’t
know anything about it. I’m hoping I’ll never find out. I’m sure
they told me, but I don’t remember.”
Challenges
Most patients affirmed the value of having a CVC in place. One
patient with a port-a-cath described it as a “blessing.” Another
with a port-a-cath said it was a “godsend.” Many wished they
had
known about CVCs and received one earlier in their treatments
because it simplified phlebotomy and medication
administration.
One patient with a port-a-cath said, “There’s no difficult part. I
wish I was born with one.” Another patient with a port-a-cath

said,
“I’ve thought it’s not much to do to take care of it. Myself and
the
port have gotten along really well.”
However, 28 participants described at least one difficulty in
having or caring for a CVC. They noted problems with sleeping,
showering, bathing, and forgetting about being tethered. One
patient who had a port-a-cath with a home infusion pump said,
It’s just kind of awkward to make sure I don’t get hung up
on it. Sleeping is no problem. I just unwrap it. We figured
that out on the first night. It did fall off the bed once. It felt
like an anchor.
A patient who had a port-a-cath with a home infusion pump
said, “The only thing is carrying that stupid thing around. And
hugs—they hurt. The other week, [my wife] came over and gave
me a big, strong hug, and it really hurt.”
Others noted practical problems, such as de-accessing the port
unintentionally and port malfunctions. One patient who had a
port-a-cath with a home infusion pump said, “Last time the
needle
fell out while I was at home. I think it was the way it was taped
up.
I called them and they re-established it.” Another patient who
had
a port-a-cath said, “With the first one, I’d have to jump around
to
get it to work sometimes. This one is beautiful. This one is
good.”
Four respondents experienced a CLABSI, but they generally
took the expected complication in stride. One patient with a
port-a-cath who experienced a CLABSI said,

It got infected after two weeks. Had a week at the [hospi-
tal]. They put in a PICC, and then they had to bring me back
again a few days later to rewire it, to make sure it wasn’t
going to cause any more problems. It was only accessed
once during that two-week period.
Another patient who had a port-a-cath with a home infusion
pump who experienced a CLABSI said, “They just had some
bacte-
remia in one of the ports, so I’m just off two weeks on
antibiotics.”
Patients offered several recommendations for the cancer center
to improve the experience of having a central line. Five patients
said they desired more information and education about the
avail-
ability and use of CVCs, and six said they wanted more
consistent
care by staff, including cleaning and injection technique. Three
patients expressed the desire for more product choices, such as
small bags or better attachments to allow for more convenient
home administration.
Discussion
In this exploratory project, information was elicited from
adult patients with cancer about the use and care of CVCs. The
authors learned that patients were astute observers, readily
identifying variation in practice among nurses. A minority of
patients expressed uncertainty about what to do if the dressing
became loose or wet, or how to recognize signs of infection.

Patients’ observations suggested at least two opportunities
to reduce the risk of CLABSIs associated with CVCs in
immune-
compromised hosts. First, the observations highlighted opportu-
nities to standardize line care. Nurses working in the same orga-
nization, in the same unit, and treating patients with similar
con-
ditions performed line care in ways that were readily discernible
by patients. Those differences in care may reflect inconsistent
training and oversight, a lack of consensus in the profession
about
the components of appropriate care, practice drift, individual
style, or a combination of factors. Eliciting patients’
observations
of care on a routine basis may help nurse leaders identify oppor-
tunities to educate frontline staff and standardize care.
Second, patient education may play a critical role in line
safety in patients with CVCs. Some patients described knowl-
edge deficits regarding loose dressings, wet dressings, and
signs of infection. Several remembered receiving instruction,
but had not retained the information. By asking patients how
they would manage common CVC-related scenarios, oncology
nurses could update ongoing patient assessments and provide
targeted education and training. Moller, Borregaard, Tvede, and
Adamsen (2005) demonstrated a greater than 50% reduction in
the rate of CVC-related infections among patients with hema-
tologic malignancies who received individualized, supervised
education regarding the care of Hickman lines.
Implications for Nursing
A deeper understanding of CVC care represents an opportu-
nity to improve the safety of patients with cancer. Central line

bundles—collections of best practices for preventing infec-
tions—have demonstrated the feasibility of breakthrough im-
provements in the safety of bedside lines in adult intensive care
units (Pronovost et al., 2010). The bundles typically include the
use of maximal barrier precautions during insertion, chlorhexi-
dine antisepsis, avoidance of femoral insertion, and timely cath-
eter removal. Rinke et al. (2012) reported a reduction in
CLABSIs
among pediatric patients with cancer from 2.25 to 1.79
CLABSIs
per 1,000 central lines, just days after the introduction of a line
maintenance bundle at Johns Hopkins Children’s Center.
Because the infection risks associated with long-term CVCs
in patients with cancer relies on meticulous line care, future
initiatives should focus on scrubbing the hub, minimizing line
accesses, optimizing line flushes, the use of alcohol- or
antibiotic-
impregnated caps, and timely removal of lines. New regulations
under the Affordable Care Act (2013) require certain cancer
cen-
ters to report CVC infection rates quarterly. That information
will
be helpful in benchmarking performance and will help clarify
the
epidemiology of CLABSIs among immune-compromised
patients
with long-term catheters.
While awaiting the results of national reporting, healthcare
providers should take advantage of patients’ observations about
central line care. Nursing leaders should work to standardize
line care within their cancer centers and with partner homecare
organizations. In addition, patients should be educated more ef-
fectively about the care of their CVCs, using verbal, written,
and

electronic instructions that are clear and accessible to patients
with varying degrees of literacy. Patients and their families
need
a better understanding of line care, instructions about infection,
and advice about caring for mishaps (e.g., loose or wet
dressings).
Oncology nurses can play a critical role in all of those matters,
drawing on patient education resources available from the CDC
(www.cdc.gov/HAI/bsi/CLABSI-resources.html).
Limitations and Conclusion
The current project’s generalizability is limited by the small
number of respondents and the potential for selection bias.
Patients at the cancer center in the current study may not be
representative of patients with cancer elsewhere. Participants
in the current study may be more or less articulate and obser-
vant than the general population. Like any interview survey,
responses also were susceptible to recall and social desirability
bias. Despite those potential limitations, the authors believe
that eliciting patients’ observations about their own care is very
valuable. Many patients are astute observers of their care, and
nurses can learn from their observations.
References
Affordable Care Act; PPS-Exempt Cancer Hospital Quality
Report-
ing Program, 78 Fed. Reg. 50837 (August 19, 2013) (to be
codified
at 42 C.F.R. pts. 412, 413, 414, et al.).
Centers for Disease Control and Prevention. (2011). Vital signs:
Central

line-associated blood stream infections—United States, 2001,
2008,
and 2009. Morbidity and Mortality Weekly Report, 60, 243–
248.
Laura, R., Degl’Innocenti, M., Mocali, M., Alberani, F., Boschi,
S.,
Giraudi, A., . . . Peron, G. (2000). Comparison of two different
time interval protocols for central venous catheter dressing
in bone marrow transplant patients: Results of a randomized,
multicenter study. The Italian Nurse Bone Marrow Transplant
Group (GITMO). Haematologica, 85, 275–279.
Mermel, L.A., Allon, M., Bouza, E., Craven, D.E., Flynn, P.,
O’Grady,
N.P., . . . Warren, D.K. (2009). Clinical practice guidelines for
the
diagnosis and management of intravascular catheter-related in-
fection: 2009 update by the Infectious Diseases Society of
Amer-
ica. Clinical Infectious Diseases, 49, 1–45. doi:10.1086/599376
Mollee, P., Jones, M., Stackelroth, J., van Kuilenburg, R.,
Joubert, W.,

Faoagali, J., . . . Clements, A. (2011). Catheter-associated
blood-
stream infection incidence and risk factors in adults with
cancer: A
prospective cohort study. Journal of Hospital Infection, 78, 26–
30.
Moller, T., Borregaard, N., Tvede, M., & Adamsen, L. (2005).
Patient
education—A strategy for prevention of infections caused by
per-
manent central venous catheters in patients with haematological
malignancies: A randomized clinical trial. Journal of Hospital
Infection, 61, 330–341. doi:10.1016/j.jhin.2005.01.031
O’Grady, N.P., Alexander, M., Burns, L.A., Dellinger, E.P.,
Garland,
J., Heard, S.O., . . . Saint, S. (2011). Guidelines for the
prevention
of intravascular catheter-related infections. American Journal
Implications for Practice
u Ask patients about their central line care to identify improve-
ment opportunities.
u Standardize central venous catheter care to minimize practice
variation.

u Teach patients how to address loose or wet dressings and
signs of infection.
Oncology Nursing
of Infection Control, 39 (Suppl. 1), S1–S34.
Pronovost, P., Needham, D., Berenholtz, S., Sinopoli, D., Chu,
H.,
Cosgrove, S., . . . Goeschel, C. (2006). An intervention to de-
crease catheter-related bloodstream infections in the ICU. New
England Journal of Medicine, 355, 2725–2732.
Pronovost, P.J., Goeschel, C.A., Colantuoni, E., Watson, S.,
Lubom-
ski, L.H., Berenholtz, S.M., . . . Needham, D. (2010).
Sustaining
reductions in catheter related bloodstream infections in Michi-
gan intensive care units: Observational study. BMJ, 340, c309.
Rinke, M.L., Chen, A.R., Bundy, D.G., Colantuoni, E., Fratino,
L.,
Drucis, K.M., . . . Miller, M.R. (2012). Implementation of a
central

line maintenance care bundle in hospitalized pediatric oncology
patients. Pediatrics, 130, E996–E1004.
Scott, D.R. (2009). The direct medical costs of healthcare-
associ-
ated infections in U.S. hospitals and the benefits of prevention.
Retrieved from http://1.usa.gov/RUbCoo
Schiffer, C.A., Mangu, P.B., Wade, J.C., Camp-Sorrell, D.,
Cope, D.G.,
El-Rayes, B.F., . . . Levine, M. (2013). Central venous catheter
care
for the patient with cancer: American Society of Clinical Oncol-
ogy clinical practice guideline. Journal of Clinical Oncology,
31, 1357–1370. doi:10.1200/JCO.2012.45.5733
Tomlinson, D., Mermel, L.A., Ethier, M.C., Matlow, A.,
Gillmeister, B.,
& Sung, L. (2011). Defining bloodstream infections related to
cen-
tral venous catheters in patients with cancer: A systematic
review.
Clinical Infectious Diseases, 53, 697–710.
doi:10.1093/cid/cir523
Wolf, H.H., Leithäuser, M., Maschmeyer, G., Salwender, H.,

Klein,
U., Chaberny, I., . . . Mousset, S. (2008). Central venous
catheter-
related infections in hematology and oncology: Guidelines of
the Infectious Diseases Working Party of the German Society of
Hematology and Oncology. Annals of Hematology, 87, 863–
876.
For Further Exploration
Use This Article in Your Next Journal Club
Journal club programs can help to increase your ability to
evaluate the literature and translate those research findings to
clinical practice, educa-
tion, administration, and research. Use the following questions
to start the discussion at your next journal club meeting.
1. What is the clinical problem that is addressed in the article?
Why is the problem important to members of the journal club?
2. What were the outcomes or recommendations for practice,
education, administration, and/or research based on the
evidence presented?
3. Which of the recommendations would you consider
implementing in your setting? Why or why not?
4. What would be the next steps in applying the information
presented in the article in your setting?
Visit http://bit.ly/1m98Sf3 for details on creating and
participating in a journal club. Photocopying of this article for
discussion purposes is permitted.

Copyright of Clinical Journal of Oncology Nursing is the
property of Oncology Nursing
Society and its content may not be copied or emailed to multiple
sites or posted to a listserv
without the copyright holder's express written permission.
However, users may print,
download, or email articles for individual use.
O
P
a
D
a
b
a
A
R
R
A
K
B
C
C
C
i
C
I

I
S
I
c
o
r
C
h
0
Intensive and Critical Care Nursing 43 (2017) 12–22
Contents lists available at ScienceDirect
Intensive and Critical Care Nursing
j ourna l ho m epage: www.elsev ier .com/ iccn
riginal article
revention of central venous line associated bloodstream
infections in
dult intensive care units: A systematic review
iana Carolina Velasquez Reyesa,∗ , Melissa Bloomerb, Julia
Morpheta
Monash University, School of Nursing and Midwifery Peninsula
campus, McMahons Road, Frankston VIC, 3199, Australia
Deakin University, School of Nursing and Midwifery, PO Box
20000, Geelong, VIC, AUS 3217, Australia
r t i c l e i n f o

rticle history:
eceived 27 February 2017
eceived in revised form 3 May 2017
ccepted 23 May 2017
eywords:
lood stream infection prevention
atheter
atheterisation
entral line associated blood stream
nfection
entral venous line
nfection prevention-control
ntensive care
ystematic review
a b s t r a c t
Background: In adult Intensive Care Units, the complexity
of patient treatment requirements make the
use of central venous lines essential. Despite the potential
benefits central venous lines can have for
patients, there is a high risk of bloodstream infection
associated with these catheters.
Aim: Identify and critique the best available evidence
regarding interventions to prevent central venous
line associated bloodstream infections in adult intensive
care unit patients other than anti-microbial
catheters.
Methods: A systematic review of studies published from
January 2007 to February 2016 was undertaken.
A systematic search of seven databases was carried out:
MEDLINE; CINAHL Plus; EMBASE; PubMed;
Cochrane Library; Scopus and Google Scholar. Studies

were critically appraised by three independent
reviewers prior to inclusion.
Results: Nineteen studies were included. A range of
interventions were found to be used for the preven-
tion or reduction of central venous line associated
bloodstream infections. These interventions included
dressings, closed infusion systems, aseptic skin preparation,
central venous line bundles, quality improve-
ment initiatives, education, an extra staff in the Intensive
Care Unit and the participation in the ‘On the
CUSP: Stop Blood Stream Infections’ national programme.
Conclusions: Central venous line associated bloodstream
infections can be reduced by a range of inter-
ventions including closed infusion systems, aseptic
technique during insertion and management of the
central venous line, early removal of central venous lines
and appropriate site selection.
© 2017 Elsevier Ltd. All rights reserved.
Implications for clinical practice
• Interventions other than high cost devices such as
antimicrobial-coated catheters offer an alternative or
complementary solution
to central venous line associated bloodstream infections in adult
Intensive Care Units.
suc
s hav
• The findings in this study show that low cost interventions
venous line bundles and aseptic management of these device
bloodstream infections rates.

ntroduction
Patients admitted to Intensive Care Units (ICUs) require spe-
ialised management of life threatening conditions. The
complexity
f the treatment and the procedures that patients in ICU may
equire, make central venous lines essential (College of Intensive
are Medicine of Australia and New Zealand [CICM], 2011).
High
∗ Corresponding author.
E-mail address: [email protected] (D.C. Velasquez Reyes).
ttp://dx.doi.org/10.1016/j.iccn.2017.05.006
964-3397/© 2017 Elsevier Ltd. All rights reserved.
h as education, surveillance, checklists, reporting and central
e positive outcomes in reducing central venous line associated
volume intravenous fluids, parenteral nutrition, cardiovascular
measurements, medication administration and blood infusions
all
require the use of central venous lines (Walder et al., 2002;
World
Health Organization, 2014). Despite their potential benefits, the
risk
of central venous line associated bloodstream infections
(CLABSI)
is high (Siempos et al., 2009). A CLABSI is a laboratory-
confirmed
bloodstream infection (BSI) in a patient who had a central
venous
line within the 48 hours prior to development of the BSI, not
related

to an infection at another site (Centre of Control and Disease
Prevention, 2014; Fagan et al., 2013; Kallen et al., 2010;
O’Grady
et al., 2011, 2002).
dx.doi.org/10.1016/j.iccn.2017.05.006
http://www.sciencedirect.com/science/journal/09643397
http://www.elsevier.com/iccn
http://crossmark.crossref.org/dialog/?doi=10.1016/j.iccn.2017.0
5.006&domain=pdf
mailto:[email protected]
dx.doi.org/10.1016/j.iccn.2017.05.006
and C
i
f
H
a
2
c
e
a
2
s
o
f
f
(
i
d
v
o

i
o
f
r
M
a
t
2
w
C
f
o
W
o
I
•
•
O
s
e
P
•
•
•

D.C. Velasquez Reyes et al. / Intensive
A 2010 study conducted in the United States of America (USA)
dentified that about 41,000 patients developed CLABSI (Centre
or Disease Control and Prevention, 2011; Virginia Department
of
ealth, 2013). Around 18,000 of those affected were ICU
patients,
nd one in four may die (Centre for Disease Control and
Prevention,
011; Virginia Department of Health, 2013). CLABSI is also
asso-
iated with increased cost in patient care (Walder et al., 2002),
stimated at USD$33,000 (Stevens et al., 2014).
Consequently, there is increased interest in ways to reduce
nd prevent CLABSI (Dumont and Nesselrodt, 2012; O’Grady et
al.,
011). In 2008, a systematic review was undertaken evaluating
trategies other than antimicrobial-coated catheters to reduce risk
f CLABSI in the ICU (Ramritu et al., 2008b). In 2011, the
Centre
or Disease Control and prevention published updated guidelines
or the prevention of intravascular catheter associated infections
O’Grady et al., 2011, 2002). Despite these guidelines, and
advances
n understanding related to infection patterns, pathogen agents,
ifferent pathogenesis, epidemiology and new diagnosis and pre-
ention techniques in the last decade (Kim et al., 2011), no
update
f this systematic review has been undertaken.
The aim of this systematic review was to identify all existing
nterventions to prevent and/or reduce CLABSI in adults in ICU,
ther than antimicrobial-coated catheters. Literature published
rom 2007 was included, as that is when the previous systematic

eview was undertaken (Ramritu et al., 2008b).
ethods
This systematic review followed the Cochrane Effective
Practice
nd Organisation of Care Review Group (EPOC) recommenda-
ions to assess quality in systematic reviews (Chandler et al.,
013). Randomised controlled trials and observational studies
hich investigated interventions for the prevention or reduction
of
LABSI in adult ICU patients were included. The quality of
evidence
or each included study was determined based on the Grades of
Rec-
mmendations, Assessment, Development and Evaluating
(GRADE)
orking Group (Schünemann et al., 2011). Only studies with a
high
r moderate quality rating were included.
nclusion criteria
Studies conducted in ICUs with adult patient populations were
included.
All interventions which sought to prevent and/or reduce
CLABSI
including the CDC recommended interventions (Centre for
Disease Control and Prevention, 2011; Centre of Control and
Disease Prevention, 2014; O’Grady et al., 2011, 2002) and the
Institute of Healthcare Improvement (IHI) compilation of
bundle
of interventions designated to work together to reduce CLABSI
were included.

utcome measures
The following outcome measures were examined following the
uggestions given by the Cochrane EPOC Review Group
(Chandler
t al., 2013).
rimary outcomes
Central venous line associated bloodstream infection rates (per
1000 central venous line days)
Identification and incidence rate of pathogen agents identified
in the colonised central venous lines detected (laboratory test
report data)
Mortality and comorbidity rates related to CLABSI.
ritical Care Nursing 43 (2017) 12–22 13
• Increased length of hospitalisation (measured in days) caused
by
the presence of CLABSI.
Secondary outcomes
• Measurement of the time (measured in days) from central
venous
line insertion to removal.
• Length of stay in ICU, measured from the day of admission to
ICU
to the day of discharge from ICU.
Exclusion criteria

• Studies published in languages other than English.
• Non-academic studies, conference abstracts, oral presentation
or
not original research.
• Characteristics of participants not reported, no baseline data,
studies with no clear description of the intervention applied.
• Studies with unclear aim, methodology, or data collection, or
those with missing data were excluded.
• Studies conducted wholly or in part with paediatric
populations
where the results were not reported separately.
• Studies where ICUs were included together with another ward
(e.g. emergency department, coronary care units) where the
results were not reported separately.
• Studies where antimicrobial-coated catheters were used were
excluded from this review because several systematic reviews
have recently been published on this topic (Antonelli et al.,
2012;
Liu et al., 2014; Raad, 2012; Ramritu et al., 2008a).
Search strategy
MEDLINE; CINAHL Plus; EMBASE; PubMed; Cochrane
Library,
Google Scholar and Scopus databases were searched using the
following keywords (or abbreviations) and MeSH search terms;
‘catheteri*ation-central venous’, infection*, prevention*, blood-
stream*.
Data collection

The Cochrane Collaboration RevMan software (The Cochrane
Collaboration, 2014) was used for data entry and management.
The data were extracted following The Cochrane’s manual
check-
list (Higgins and Green, 2011). One researcher screened the
titles
and abstracts of each study. The three researchers then analysed
the full-text of 87 studies meeting the inclusion criteria for full
text
assessment.
Assessment of methodological quality
Three researchers assessed the quality of each study, to deter-
mine inclusion, using the Meta-Analysis of Statistics
Assessment
and Review Instrument (MAStARI) tool (Joanna Briggs
Institute,
2014).
Assessment of risk of bias in included studies
The Cochrane Risk and Bias Assessment (RoBANS) tool and
guideline were applied to each of the included studies (Higgins
et al., 2011).
Data synthesis
Outcome measures and statistical analysis, such as relative risk
(RR), probability (p), Pearson Correlation Coefficient,
Confidence
Interval (CI) and the statistical power of the mean were
analysed.

14 D.C. Velasquez Reyes et al. / Intensive and Critical Care
Nursing 43 (2017) 12–22
1,500 stud ies iden�fied
825 through database search & 675 through Google Scholar
search
87 full text studies ass ess ed for eligibili ty
68 stud ies exclud ed a�er full text cri�cal app raisal:
3 Full text wri �en in a language other tha n E nglish
16 not in ICU se�ng, not central line catheters
14 Oral presenta�ons/ conference/posters stud ies
13 Par�al or full use of an �microbial coated catheters
3 Cha racteris�cs of par�cipants not reported, no baseline data
1 No clear descrip�on or correla�on of the interven�on
5 Poor methodology measurement of the interven�on related
with the aim of
stud y. No confound er discuss ed
5 Miss ing data, lack of central line ass ociated bloodstream
infec�ons rate
reported
1 Different bun dles applied during interven�on bu t not
reported or considered in
the outcomes measurements, no confoun ders considered
1 Different ty pes and brand s of cap s were used duri ng

interven�on.
Cha racteri s�cs of pa r�cipants not reported
5 Weak methodology, surveys an d self-reported da ta,
correla�on betwee n
interven�on and outcome not clear, miss ing data
characteris�cs of pa r�cipants not
reported.
1 Vari ous interven�ons were ap pli ed duri ng stud y, no clear
indica�on which
interven�on redu ced the CLABSI rate
1,41 3 stud ies exclud ed:
651 duplicates
371 non central line catheters
221 non adu lt ICU se�ng
150 non-acad emic research stud ies
17 not Engli sh langua ge
3 not pub lished a�er 200 6
1,50 0 stud ies scree ned by �tle/ab stract
A flo
W
t
h
s

R
S
t
R
o
19 stud ies includ ed in the systema�c review
Fig. 1. PRISM
hen the data was homogenous, a Forest Plot was created to
illus-
rate the strength of the effect of the intervention. Due to the
eterogeneity of the interventions and their reported results,
meta-
ynthesis was undertaken of the qualitative research studies.
esults
earch results
From the database searches, a total of 1500 studies were iden-
ified (Fig. 1).
isk of bias in included studies
All the included randomised controlled studies had a low risk
f bias (Kwakman et al., 2012; Marsteller et al., 2012; Mimoz et
al.,
w diagram.
2007; Pedrolo et al., 2014; Speroff et al., 2011; Timsit et al.,
2012;
Timsit et al., 2009; Yousefshahi et al., 2013) due to their

random
sequence generation, blinding of outcome assessment and inter-
vention exposure measurement. Eleven studies had unclear risk
of bias, because the interventions could not be blinded (e.g., the
nature of the interventions, or methodology of reporting.
However,
the studies were include as the confounders/bias were
considered
in the reporting of results (Bonello et al., 2008; Cherifi et al.,
2013;
Jeong et al., 2013; Maki et al., 2011; Marsteller et al., 2014;
McLaws
and Burrell, 2012; Parikh et al., 2012; Rangel-Frausto et al.,
2010;
Scheithauer et al., 2014; Tang et al., 2014; Vilins et al., 2009).
None
of the studies included in this review reported a high risk of
bias.
After the full text quality appraisal was independently under-
taken by the three researchers, and following the risk of bias
assessment, 19 studies were included in this systematic review
(Fig. 1).
and Critical Care Nursing 43 (2017) 12–22 15
I
c
2
2
e

e
t
2
2
i
M
R
2
v
c
2
2
b
n
i
i
S
s
2
e
t
e
D
i
P
T
n
d
e
(
e
2
3

t
d
d
(
d
c
C
T
1
p
s
m
0
s
d
d
d
e
s
m
c
2
nterventions of included studies
The studies examined a variety of interventions, including edu-
ation based interventions (Bonello, Fletcher, 2008; Cherifi,
Gerard,
013; Scheithauer et al., 2014; Speroff et al., 2011; Tang et al.,
014), skill-mix based interventions (Bonello et al., 2008;
Cherifi
t al., 2013; Marsteller et al., 2014; Marsteller et al. 2012; Parikh
t al., 2012, Scheithauer et al., 2014), equipment based interven-
ions (Maki et al., 2011; Rangel-Frausto et al., 2010; Vilins et
al.,

009), various dressings (Pedrolo et al., 2014; Scheithauer et al.,
014, Timsit et al., 2012; Timsit et al., 2009) and aseptic based
nterventions (Bonello et al., 2008; Jeong et al., 2013;
Kwakman,
uller, 2012; McLaws and Burrell, 2012; Mimoz, Villeminey,
2007;
angel-Frausto et al., 2010; Speroff et al., 2011; Yousefshahi et
al.,
013). Several studies evaluated the use of the different central
enous line insertion bundles including the Institute for Health-
are Improvement (IHI) bundle (Bonello et al., 2008; Cherifi et
al.,
013; Jeong et al., 2013; McLaws and Burrell, 2012; Parikh et
al.,
012; Pedrolo et al., 2012). Many of these studies combined the
IHI
undle with other interventions, including education (web semi-
ars, monthly educational sessions, auditing and feedback based
nfection programs) (Yousefshahi et al., 2013), face to face
meet-
ngs, teleconferences and/or online in-services (Bonello et al.,
2008;
peroff et al., 2011; Tang et al., 2014), teamwork strategies and
tandardised data collection tools (Bonello et al., 2008; Jeong et
al.,
013), surveillance interventions (Jeong et al., 2013; Scheithauer
t al., 2014; Tang et al., 2014) and other care bundles (e.g. the
ven-
ilator associated pneumonia bundle) (Bonello et al., 2008;
Speroff
t al., 2011).
ressings

Five studies examined the effect of various central venous line
nsertion site dressings on CLABSI rates (Kwakman et al.„ 2012;
edrolo et al., 2014; Scheithauer et al., 2014; Timsit et al., 2012;
imsit et al., 2009). Four studies compared chlorhexidine impreg-
ated dressings with other dressings including medical honey
ressing (Kwakman et al., 2012), standard dressing (Scheithauer
t al., 2014; Timsit et al., 2009), sterile gauze and micropore
tape
Pedrolo et al., 2014), transparent Tegaderm 3 M dressing
(Timsit
t al., 2012), Tegaderm Transparent Film Dressing 3 M (Timsit
et al.,
012) and highly adhesive Tegaderm HP Transparent Film
Dressing
M (Timsit et al., 2012).
There was no significant difference in CLABSI and skin
colonisa-
ion rates when chlorhexidine dressings were compared with
other
ressings (Table 1). However, one study found that
Chlorhexidine
ressings lowered the number of Gram-positive bacterial
infections
Scheithauer et al., 2014). In one study comparing chlorhexidine
ressings with standard dressings, dressings in both cohorts were
hanged at either three or seven days. The authors reported that
LABSI was less common with chlorhexidine dressings (Table
1).
he authors also reported a catheter colonisation of 142 out of
657catheters (7.8%) in the three day dressing change group
(10.4
er 1000 catheter-days) and 168 of 1828 catheters (8.6%) in the
even day dressing change group (11.0 per 1000 catheter-days), a

ean absolute difference of 0.8% (95% CI, −1.78% to 2.15%)
(HR,
.99; 95% CI, 0.77–1.28) (Timsit et al., 2009). The remaining
four
tudies reported changing the dressings every seven days unless
ressing edges detached, dressing integrity was compromised or
ischarge accumulated in the catheter opening (leaking or soiled
ressings) (Kwakman et al., 2012; Pedrolo et al., 2014;
Scheithauer
t al., 2014; Timsit et al., 2012). In addition to the dressings,
these
tudies also used other interventions to reduce CLABSI including
aximal sterile barriers (Timsit et al., 2012; Timsit et al., 2009),
are bundles (Pedrolo et al.„ 2014; Timsit et al., 2012; Timsit et
al.,
009), and antiseptic skin preparation prior the insertion of the
cen-
Fig. 2. Comparing open vs. closed infusion containers studies.
tral venous line (Kwakman et al., 2012; Pedrolo et al., 2014;
Timsit
et al., 2012; Timsit et al., 2009) (Table 1).
Open vs. closed infusion containers
Three studies compared open and closed infusion containers
(Maki et al.„ 2011; Rangel-Frausto et al.„ 2010; Vilins et al.,
2009).
(Table 2, Fig. 2) Open infusion containers were defined as com-
mercially available glass bottles, burettes and semi-rigid plastic
containers that must admit air (air filter or needle) to empty,
requir-

ing external venting (Maki et al., 2011; Rangel-Frausto et al.,
2010;
Vilins et al., 2009). Closed infusion containers were defined as
fully collapsible plastic containers that did not require any
exter-
nal venting to empty, with self-sealing injection ports (Viaflex
or Viaflo) (Maki et al., 2011; Rangel-Frausto et al., 2010).
Meta-
analysis indicated that closed infusion container systems
reduced
CLABSI (Fig. 2). In each of these three studies, a standard
central
venous line management protocol was in place, including hand
hygiene with alcohol based hand rub, and a care protocol docu-
menting and evaluating the gauze dressing condition.
Aseptic skin preparation
Chlorhexidine skin antiseptic was used as skin preparation prior
to central venous line insertion in ten studies (Bonello et al.„
2008;
Cherifi et al.„ 2013; Jeong et al., 2013; Kwakman et al., 2012;
McLaws and Burrell, 2012; Mimoz et al.„ 2007; Rangel-
Frausto
et al., 2010; Speroff et al., 2011; Timsit et al., 2012;
Yousefshahi
et al., 2013). However, only two studies examined the effective-
ness of the antiseptic applied at the central venous line insertion
site in the reduction of central venous line pathogen
colonization
(Mimoz et al., 2007; Yousefshahi et al., 2013). One study com-
pared topical Chlorhexidine with an antiseptic agent composed
of hydrogen peroxide (H2O2) and silver (Sanosil 2%)
(Yousefshahi
et al., 2013). The antiseptic agent composed of hydrogen per-
oxide (H2O2) and silver produced a lower number of positive

central venous line tip cultures than the Chlorhexidine,
however,
there was no significant difference between the two
(Yousefshahi
et al., 2013) (Tables 3 and 4). Skin antisepsis with 0.1% octeni-
dine dihydrochloride and 2% 2-phenoxyethanol (octenisept) was
applied in one study in combination with Chlorhexidine
dressings
(Scheithauer et al., 2014). Alcohol povidone-iodine was also
com-
pared against Chlorhexidine in four studies (Mimoz et al.,
2007;
Timsit et al., 2012; Timsit et al.„ 2009; Yousefshahi et al.,
2013) and
only one study reported a higher prevention of CLABSI when
using
Chlorhexidine as skin antiseptic compared to alcohol povidone-
iodine (Mimoz et al., 2007). One study compared a
Chlorhexidine
bath one day prior to central venous line insertion, with
Povidone-
Iodine scrub immediately preceding central venous line
insertion,
with no reduction in CLABSI rates (Yousefshahi et al., 2013)
(Table
3).
Nursing 43 (2017) 12–22
Table 1
Examination of studies comparing dressings.

Author & year Group ICUs in
sample
Patients in
sample
CLABSI n (%) Positive Culture
Swab n (%)
CLABSI/1000
catheter days
RR (95% CI) p
Kwakman et al. (2012) Control 1 106 – 36 (34) – NR 0.98
Revami (honey) and gauze 1 129 – 44 (34) –
Pedrolo et al. (2014) Chlorhexidine dressing 2 43 6 – – NR 0.52
(13.95)
Gauze and Micropore 2 42 5 – –
(11.9)
sample
Central line
days
CLABSI n (%) Positive Culture
Swab n (%)
CLABSI/1000
catheter days

RR (95% CI) p
Scheithauer et al. (2015) Chlorhexidine dressing 2 7282 11 –
1.5/1000 (0.75–2.70) <0.001
Standard dressing 2 4938 29 – 5.87/1000 (0.93–8.43)
sample
Catheters in
sample
CRBSI (n) Positive Culture
Swab n (%)
CRBSI/1000
catheter days
RR (95% CI) p
Timsit et al. (2012) Chlorhexidine dressing 12 2108 9 75 0.5
1.284 0.45
(0.67–2.45)
Adhesive dressing 12 998 10 97 1.3
Standard dressing 12 1067 12 89 1.3
Timsit et al. (2009) Chlorhexidine dressing 7 1825 – – 1.3 0.24
0.05
(0.09–0.65)
Standard dressing 7 1953 – – 0.4
Note: ICU = Intensive Care Unit; NR = not reported; CLABSI =
Central line associated blood stream infection; CRBSI =
Catheter related blood stream infection; RR = Risk Ratio.

Table 2
Comparing open vs. closed infusion containers studies.
Author & Year Group No. ICUs in
sample
No. of patients in
sample
Rate of CLABSI per
1000 central
line-days
(infections/days)
Rate of CLABSI per
1000 central
line-days
(%)
RR
(95%CI)
p
Maki et al. (2011) Open 15 2237 153/15,189 10.2 0.33 <0.001
Closed 15 2136 45/13,456 3.3 (0.24–0.46)
Rangel-Frausto et al. (2010) Open 4 548 59/3661 16.1 0.20
<0.001
Closed 4 548 13/4055 3.2 (0.11–0.36)
Vilins et al. (2009) Open 3 483 28/4297 6.5 0.49 0.03
Closed 3 642 13/4041 3.2 (0.26–0.95)
Table 3

Examination of studies comparing antiseptics.
Author & Year Group ICUs in
sample
Patients in
sample
CRBSI Catheter Tip
Positive Culture n
(%)
CRBSI/1000
catheter days (%)
RR (95%CI) P
Yousefshai et al.
(2013)
Chlorhexidine 3 113 – 29 – 1.05 0.75
(21.3) (0.76–1.45)
Sanosil 2% 3 136 – 26 –
(23.0)
Mimoz et al. (2007) Chlorhexidine 1 242 4 28 1.7 2.01 0.002–
0.009
(11.6) (1.24–3.24)
Alcohol based-Povidone-iodine 1 239 10 53 4.2 1.87
N = Risk
C

t
M
S
e
r
r
w
l
2
e
r
ote: CRBSI = Catheter Related Bloodstream Infection, ICU =
Intensive Care Unit, RR
entral venous line bundles
Seven studies used central venous line bundles as an interven-
ion (Bonello et al., 2008; Cherifi et al., 2013; Jeong et al.,
2013;
cLaws and Burrell, 2012; Parikh et al., 2012; Pedrolo et al.,
2014;
cheithauer et al., 2014; Speroff et al., 2011; Tang et al., 2014;
Timsit
t al., 2012). A key focus of central venous line bundles is early
emoval of central venous lines (Table 5). The heterogeneity of
the
eported data restricted meta-analysis, therefore meta-synthesis
as conducted. Three studies implemented the central venous
ine bundle outlined by the IHI (Bonello et al., 2008; Jeong et
al.,
013; Tang et al., 2014). This bundle has been examined in
differ-
nt studies, and results indicated a positive reduction in CLABSI
ates (Al-Tawfiq et al., 2012; Blot et al., 2014; Sacks et al.,
2014)

(22.2) (1.18–2.96)
Ratio.
(Table 6). Three studies used alternative bundles together with
multiple interventions to reduce CLABSI, with all reporting a
reduc-
tion in infection rates (Cherifi et al., 2013; McLaws and
Burrell,
2012; Yousefshahi et al., 2013) (Table 6). As a key component
of the
central venous line bundle, the early removal of central venous
line
was examined as an effective practice to reduce CLABSI
(McLaws
and Burrell, 2012). This study estimated probabilities for
CLABSI at
different dwell times to identify the dwell time that was closest
to being infection free, less than1 in 100 chance of infection,
they
reported the safest dwell time was the lowest cumulative
probabil-
ity of CLABSI, 1 in 100 chance, for a cumulative catheter dwell
time
of seven days giving an adjusted CLABSI rate of 1.8/1000 line
days
(McLaws and Burrell, 2012). This is consistent with other
studies
D.C. Velasquez Reyes et al. / Intensive and Critical Care
Nursing 43 (2017) 12–22 17

Table 4
Aseptic skin preparation used in each study.
Bonello et al. (2008) Not specified
Cheriffi et al. (2013) Skin antisepsis was performed with 0.5%
chlorhexidine in 70% alcohol (Cedium® , QUALIPHAR) or
with 5% alcoholic
povidone-iodine (Iso-Betadine® solution hydroalcoolique,
MEDA Pharma).
Jeon et al. (2013) Skin antisepsis was performed with
Chlorhexidine (2% chlorhexidine in 70% of one of the
following: isopropyl alcohol,
alcohol, povidone-iodine, or a mixture of alcohol and
povidoneiodine).
Kwakman et al. (2012) Skin antisepsis was performed with
0.5% chlorhexidine in 70% alcohol.
Mcklaws et al. (2012) Skin antisepsis was performed with 2%
alcoholic chlorhexidine.
Mimoz et al. (2007) Skin antisepsis was 5% povidone-iodine in
70% ethanol (Betadine Alcoolique; Viatris Pharmaceuticals,
Meı́rignac,
France) or a combination of 0.25% chlorhexidine gluconate,
0.025% benzalkonium chloride, and 4% benzylic alcohol
(Biseptine; Bayer HealthCare, Gaillard,France).
Rangel et al. (2010) Not specified.
Speroff et al. (2011) Not specified use of chlorhexidine skin
antisepsis.
Timsit et al. (2012) Skin preparation was with alcoholic
povidone-iodine (PVI) or alcoholic chlorhexidine solution in
accordance to
standard procedure in each ICU. First, the insertion site was

scrubbed with a detergent (4% aqueous PVI solution,
Betadine Scrub; Viatris Pharmaceuticals, Merignac,France) or
4% chlorhexidine solution (Hibiscrub; Molnlycke Health
Care, Wasquehal, France); rinsed with sterile water; and dried
with sterile gauze. An alcohol-based antiseptic solution
(5% PVI in 70% ethanol [Betadine Alcoholic
Solution
; Viatris Pharmaceuticals] or 0.5% chlorhexidine, 67% ethanol
[Molnlycke Health Care]; or 0.25%
Healthcare, Gaillard, France]) was
Yosefshahi et al. (2013) Skin preparation was bath with C
Table 5
Institution of Healthcare Improvement IHI central venous line
bundles.
Central venous line bundles strategies compiled by the IHI
Hand hygiene
Maximal sterile barrier precautions during insertion
Chlorhexidine skin antisepsis
Daily assessment of central vascular catheter necessity
e

s
C
b
v
t
T
f
M
Q
2
2
b
e
l
a
2
S
m
o
l
t

r
2
E
p
S
i
t
m
Prompt removal of central venous lines
Avoidance of femoral site
xamining the effect of a central venous line bundle on CLABSI
with
imilar positive results (Furuya et al., 2011; , Loveday et al.,
2014).
ombining multiple interventions with central venous line
undles
A variety of initiatives that could be combined with central
enous line bundles (Table 5) primarily focussed on staff educa-
ion, surveillance, development of tools and teamwork practices.
he combination of any of these interventions with bundles were

ound to reduce CLABSI (Bonello et al., 2008; Cherifi et al.,
2013;
cLaws and Burrell, 2012; Tang et al., 2014).
uality improvement initiatives
These initiatives included compliance checklists (Bonello et al.,
008; Jeong et al., 2013; McLaws and Burrell, 2012; Tang et al.,
014), surveillance (Cherifi et al., 2013; Tang et al., 2014), feed-
ack (Jeong et al., 2013), hand hygiene education programs
(Jeong
t al., 2013; Speroff et al., 2011), visual promotion of central
venous
ine care campaigns (Jeong et al., 2013; Speroff et al., 2011),
cre-
tion of collaborative teams (Jeong et al., 2013; Speroff et al.,
011), tools, guidelines or protocols (McLaws and Burrell, 2012;
peroff et al., 2011). The virtual collaborative intervention
included
onthly educational conference calls, web seminars, individual
nline coaching and email report access related to central venous
ine management (Speroff et al., 2011). These different combina-
ions of interventions resulted in a significant reduction in

CLABSI
ates (Bonello et al., 2008; Cherifi et al., 2013; McLaws and
Burrell,
012; Tang et al., 2014) (Table 6).
ducation
In four studies the IHI bundle was combined with educational
rograms delivered in the ICU (Cherifi et al., 2013; Jeong et al.,
2013;
peroff et al., 2011; Tang et al., 2014). It included
interdisciplinary
mprovement team implementing organisational changes related
o the central venous line bundle, they introduced sharing goals
and
ethods by collaborative charter, monthly conferences calls face
chlorhexidine, 0.025% benzalkonium chloride, 4% benzyl
alcohol [Biseptine Bayer
then applied for at least 1 min.
hlorhexidine 2%. and 10% Povidone-Iodine.
to face, learning sessions at least (three per month), education

in
‘Plan to Do, Study Act (PDSA) methodology, bed side
checklists edu-
cation and interdisciplinary interactive team rounds. Only two
of
these studies demonstrated a significant reduction in CLABSI
rates
(Cherifi et al., 2013, Tang et al., 2014) (Table 6).
Increasing ICU medical staffing
One study examined the effect of staffing skill mix on infection
rates, by comparing infection rates before and after the
introduction
of an extra intensivist in the ICU (Parikh et al., 2012),
demonstrating
an intensivist as a cost effective and beneficial strategy in
reducing
CLABSI rates (Parikh et al., 2012) (Table 7). Not only were
more lives
saved when there was an extra intensivist in the ICU, but the
cost
of the intensivist was cheaper than the expenses associated
with a
higher CLABSI rate (Barnett et al., 2010; Parikh et al., 2012;

Stevens
et al., 2014).
Participating in on the CUSP
Two studies examined the outcomes arising from participation
in On the CUSP, a national program in the USA, and its impact
in
reducing CLABSI (Marsteller et al., 2014; Marsteller et al.,
2012).
Both studies reported significant reductions in CLABSI after
apply-
ing the intervention. The first study additional of the On the
CUSP
national program examined the positive outcome of mandatory
reporting and CLABSI reduction. After comparing CLABSI
rates from
hospitals where a mandatory reporting public reports of central
venous line associated infections rates was in place (Table 8).
Discussion
From the nineteen studies included in this review, fifteen
reported a positive impact in the reduction of CLABSI (Bonello
et al., 2008; Cherifi et al., 2013; Maki et al., 2011; Marstelleret

al.,
2014, Marsteller et al., 2012; McLaws and Burrell, 2012;
Mimoz
et al., 2007; Parikh et al., 2012; Rangel-Frausto et al., 2010;
Tang et al., 2014; Timsit et al., 2012; Timsit et al., 2009; Vilins
et al., 2009; Yousefshahi et al., 2013). Open infusion
containers,
chlorhexidine dressings, aseptic interventions for central venous
line maintenance including central venous line bundles, manda-
tory reporting, communication and continuing education based
interventions were effective in reducing CLABSI rates. In
addition,
checklists, facilitating feedback, regular rounds and supervision
and extra intensivist in the ICU were also successful
interventions.
Chlorhexidine skin preparation prior to central venous line
inser-
tion was not shown to significantly reduce the rate of CLABSI.
(Jeong

Nursing 43 (2017) 12–22
Table 6
Examination of studies comparing central line bundles.
sample
Patients in
sample
CLABSI n (%) CLABSI/1000
catheter days
RR (95% CI) p
Jeong et al. (2013) Baseline 4 79 4.7 6/1290 0.39 0.76
Intervention 4 309 1.8 7/3899 (0.11–1.39)
McLaws et al. (2012) First 12 months 37 4166 3.8 27/7176
(2.5–5.5) 0.002
Last 6 months 37 NR 1.6 26/16,100 (1.0–2.4)
Tang et al. (2014) Baseline 5 NR 1.6 17/10,325 NR 0.03
Intervention 5 481 0.6 6/9388

sample
Patients in
sample
Mean CLABSI n
(%)
Mean of
CLABSI/1000 days
RR (95% CI) p
Bonello et al. (2008) First 3 months 12 NR 0.52 5.2/1000 NR
NR
Last 3 months 12 NR 0.27 2.7/1000
Cherifi et al. (2013) Before intervention 5 1354 4.00 24/1000
0.49 0.212
(0.24–0.98)
During intervention 5 1571 1.81 12/1000
After intervention 5 1439 2.73 16/1000 1.37 0.413

(0.65–2.89)
Author & year Group Hospitals in
sample
Hospitals in Tool
kit group
Hospitals in Virtual
collaborative group
Median
CLABSI/1000
catheter days in
Tool kit group
Median
CLABSI/1000
catheter days in
Virtual
collaborative group
RR (95% CI) p

Speroff et al. (2011) Baseline 59 29 30 2.42 1.84 NR NR
(0.65–6.80) (0.00–3.83)
3 months 59 29 30 2.47 2.24
(1.48–5.35) (0.54–4.69)
6 months 59 29 30 2.54 2.28
(0.00–4.98) (0.00–3.73)
9 months 59 29 30 1.23 1.75
(0.00–3.93) (0.00–3.74)
12 months 59 29 30 1.17 1.18
(0.00–3.61) (0.00–2.71)
15 months 59 29 30 1.77 2.04
(0.00–3.30) (0.00–4.91)
18 months 59 29 30 1.16 2.76
(0.00–5.46) (0.00–4.67)
Note: ICU = intensive care unit; NR = not reported; CRBSI =
Catheter related blood stream infection.
Table 7

Examination of a study increasing ICU medical staffing.
Author & Year Group No. of ICUs in
sample
No. patients in
sample
No. CLABSI per
1000 central line
days
(infection/days)
Rate of CLABSI
per 1000 central
line days (%)
RR (95%CI) p
Parikh et al. (2012) First year before intervention 1 1113
13/1531 8.5 8.32 0.0006
(1.91–36.28)
68

N nsive
e
2
l
C
i
s
e
C
W
e
h
u
(
b
t
Last year after intervention 1 10
ote:CI = confidence interval, CLABSI = Central line
bloodstream infection, ICU = Inte
t al., 2013; Kwakman et al., 2012; Pedrolo et al., 2014; Speroff

et al.,
011).
Important findings from this study should be considered in ICUs
ooking to reduce CLABSI rates. Choice of dressing is
important.
hlorhexidine dressings were used in each study comparing
dress-
ng’s types, and are shown to have positive outcomes in
decreasing
kin flora which decreases CLABSI incidence.
This study found that Chlorhexidine skin preparation was
qually effective as alcohol-based povidone iodine for preventing
LABSI in most cases as other studies have shown (Adams and
ilson, 2012; Bashir et al., 2012), but that there was no differ-
nce between Chlorhexidine and the antiseptic agent composed
of
ydrogen peroxide (H2O2) and silver (Yousefshahi et al., 2013).
Reg-
lar/daily bathing with Chlorhexidine had no effect on CLABSI
rates

Noto et al., 2015; Seyman et al., 2014), although there was
reduced
lood culture contamination (Popovich et al., 2010). One reason
for
his finding may be the conclusion that dressing changes should
2/1185 1.7
Care Unit, RR = Risk Ratio.
be minimised to reduce CLABSI rates (O’Grady et al., 2011;
Rupp
et al., 2013). Only two studies reported side effect dermatitis
when
applying chlorhexidine dressings (Timsit et al., 2012; Timsit et
al.,
2009), no other data was collected regarding this important con-
sideration. Further analysis of skin side effects are
recommended
in future studies.
Early removal of central venous lines is recommended, ideally
before day eight (Exline et al., 2013; Mangum et al., 2013;
Weeks
et al., 2014). Early removal of central venous lines is one of the

key
features of central venous line bundles, and several studies
included
in this systematic review reported reduced CLABSI rates
associated
with bundle use (Bonello et al., 2008, McLaws and Burrell,
2012;
Tang et al., 2014). Another important feature of the central
venous
line bundles found to be reported was the aseptic skin
preparation
methods prior the insertion of central venous line. Hence central
venous line bundles should be promoted across ICUs.
D.C. Velasquez Reyes et al. / Intensive and Critical Care
Nursing 43 (2017) 12–22 19
Table 8
Examination studies analysing participation in On the CUSP:
Stop BSI National Program and mandatory reporting.

Author, year & period No. of ICU in sample Mean rate of
CLABSI per 1000
central line days according to
study quarters
RR according to study quarters
Control group Inter group Control group Inter group Control
group Inter.group
n n M M RR RR
Marsteller et al. (2012)
Baseline 22 23 2.71 4.48 1.00 1.00
1st Q NR 1.12 NR 0.25
2nd Q NR 1.83 NR 0.41
3rd Q 2.16 1.33 0.79 0.30
4th Q 0.56 0.96 0.21 0.21
5th Q 0.52 0.88 0.19 0.20
6th Q 0.83 0.85 0.31 0.19
No. of ICUs in sample Mean Rate of CLABSI per 1000 central
line days
n Group PR policy<1 year Group PR policy<1 year Group VR
policy Group NR Policy

M M M M
Marsteller et al. (2014) 1046
Baseline 2.49 1.85 2.20 1.90
1stQ 2.33 1.52 1.89 1.65
2ndQ 2.00 1.22 1.46 1.32
3rdQ 1.61 1.29 1.83 0.96
4thQ 1.49 1.24 1.38 0.96
5thQ 0.90 1.21 1.91 1.11
6thQ NR 1.16 1.11 1.15
N sociat
r 1 year
V
q
C
2
s
p
(
o
c
e

e
c
t
o
r
e
p
i
c
e
w
l
o
r
2
L
E
v
c
s
ote: BSI = Bloodstream infection, CI = Confidence interval,

CLABSI = Central line as
eported status, PR < 1 year = Public reporting had begun for one
year or less, PR >
R = Voluntary reporting.
In addition, central venous line bundles in combination with
uality improvement or educational interventions further reduces
LABSI rates (Cherifi et al., 2013; Ramritu et al., 2008b; Tang et
al.,
014). Quality improvement interventions have previously been
hown to reduce CLABSI rates (Blot et al., 2014), and are an
inex-
ensive way to improve patient outcomes in ICU.
Despite favourable outcomes with closed infusion systems
Maki et al., 2011, Rangel-Frausto et al., 2010, Vilins et al.,
2009),
pen infusion systems continue to be used in some developing
ountries such as Argentina, Brazil, Colombia and Mexico
(Garrett
t al., 2002; Macías et al., 1999; Maki et al., 2011; Rangel-
Frausto
t al., 2010; Rosenthal and Maki, 2004). Further research should
be
onducted to analyse and address the factors impeding the

change
owards closed infusion container systems in developing
countries.
Only one study included in this review examined the impact
f an additional intensivist, demonstrating a reduction on
CLABSI
ates (Parikh et al., 2012). There are however several other
studies
xamining a variety of healthcare associated infections in
different
opulations, which have similarly reported that additional
staffing
s effective at reducing healthcare associated infections and
health-
are costs (Chordas, 2004; Peters and Locke Nagele, 2010;
Spaeth
t al., 2003; Terry, 2002).
Finally, the mandatory reporting of CLABSI rates was
associated
ith reduced CLABSI rates. This finding is consistent with other
iterature (Marsteller et al., 2014), which reported the incidence

f methicillin resistant staphylococcus aureus (MRSA) is
similarly
educed by mandatory reporting (Biswal et al., 2015; Edge et al.,
007; Pearson et al., 2009; Sheps and Birnbaum, 2012).
imitations
This systematic review included only studies published in
nglish. There was also a predominant heterogeneity in the inter-
entions in the included studies. Consideration of the multiple
onfounders which could influence the outcomes of the studies
hould be taken into account.
ed bloodstream infection, ICU = Intensive Care Unit, Inter =
Intervention, NR = not
= Public reporting had begun for more than one year, Q =
Quarter RR = Risk Ratio,
Conclusion
This systematic review identified several interventions able to
reduce or prevent CLABSI. Aseptic technique, which includes
the
application of skin antiseptic pre-central venous line insertion,

and aseptic central venous line maintenance is essential. Closed
infusion systems should be used at all times. Central venous
line
bundles, which promote appropriate insertion site selection,
asep-
tic central venous line management and early removal; as well
as increased intensivist staffing were both found to contribute
to reduction and prevention of CLABSI and Quality
improvement
initiatives aimed at education and safety practices should be
under-
taken. Finally mandatory reporting CLABSI is imperative to the
prevention or reduction of CLABSI in adult ICUs.
Funding
The authors have no sources of funding to declare.
Ethical statement
Ethical statement not applicable the authors undertook a sys-
tematic review, no ethical statements to declare.
Conflict of interest

The authors have no conflict of interest to declare.
Acknowledgement
The researchers have no acknowledgements to make.
• APPENDIX A KEYWORDS AND MeSH SEACRH.
“catheterization”[MeSH Terms] OR catheterization[Text Word]
catheterisation”[MeSH Terms] OR catheterisation[Text Word].
2 and C
t
v
a
t
W
W
•
•
•

•
•
•
•
•
•
•
•
T
E
0 D.C. Velasquez Reyes et al. / Intensive
“catheterization, central venous”[MeSH Terms] OR cen-
ral catheterization[Text Word] “catheterisation, central
enous”[MeSH Terms] OR central catheterisation[Text Word]
ssociated[All Fields] AND (“infection”[MeSH Terms] OR infec-
ion[Text Word]) “infection”[MeSH Terms] OR infections[Text
ord].
“prevention and control”[Subheading] OR prevention[Text
ord].
Catheter, Central Venous

Catheters, Central Venous
Venous Catheter, Central
Venous Catheters, Central
Central Venous Catheter
Catheter Related Infections
Infection, Catheter-Related
Catheter-Associated Infections
Infections, Catheter-Associated
preventive therapy
preventive measures
able B1
xcluded studies
Author/year Reason for exclusion
Al-Tawfiq et al. (2013) Characteristics of participants not
reported, no base l
Amarasingham et al. (2007) No clear description and correlation
of the interventi
CLABSI rate prevention or reduction.
Barrera et al. (2011) Poor methodology during intervention

using alcohol
replacement of the bottles was done either the bottle
Barsuk et al. (2014) Poster, no full text access.
Berenholtz et al. (2014) Significant percentage of missing data.
No measurem
Cherry et al. (2011) Not conducted in ICU setting.
80 Not conducted in ICU setting.
DePalo et al. (2010) Use of antibacterial-impregnated catheters.
Dilek et al. (2012) Poor measurement of outcomes according to
aim and
Doherty and Axelrod (2011) No access to full text.
Duane et al. (2009) Use of antibacterial-impregnated catheters.
DuBose et al. (2008) Use of antibacterial-impregnated catheters.
(ARROW
Chlorhexidine acetate and silver sulfadiazine cathete
Flinchum et al. (2010) No access to full text.
Ghonim et al. (2012) No access to full text.
Hansen et al. (2014) Use of antibacterial-impregnated catheters.
Hopfner et al. (2012) No access to full text.
Jaggi et al. (2013) Intervention only partially applied. Use of
antibacteri
Khalid et al. (2013) Use of antibacterial-impregnated catheters.
Leblebicioglu et al. (2013) Intervention only partially applied.

Use of antibacteri
Lin et al. (2013) Poor quality in outcomes measurements, not
clear wh
characteristics of participants or confounders not me
Matocha and Montero (2012) No access to full text.
Matocha and Montero (2012) No access to full text.
McMullan et al. (2013) Poor quality in the methodology,
baseline was extend
No clear which intervention reduce CLABSI rates.
Miller et al. (2010) Poor quality in reporting study outcomes, no
confiden
Ong et al. (2011) Use of antibacterial-impregnated catheters.
(MultiMe
and benzalkonium chloride on both surfaces (Vantex
Osorio et al. (2013) Study not written in English
Parada et al. (2013) No access to full text.
Popovich et al. (2010) Poor quality in reporting of outcomes.
Characteristics
Different bundles applied during intervention but not
Ramirez et al. (2012) Poor quality in methodology, different
types and bran

reported.
Render et al. (2011) Poor methodology quality, self-reported
data, charact
Rosenthal et al. (2010) Use of antibacterial-impregnated
catheters.
Sacks et al. (2014) Use of antibacterial-impregnated catheters.
Triple lum
coated catheters were used.
Saldanha et al. (2014) No access to full text.
Seyman et al. (2014) Poor quality on the methodology,
subjective interven
Stone et al. (2007) Weak methodology, surveys and self-
reported data, c
participants not reported.
Thom et al. (2014) Poor methodology quality various
interventions were
rate.
Vigorito et al. (2011) Weak methodology self-reported data,
demographics
Weeks et al. (2014) Weak methodology self-reported data,
change of tool

ritical Care Nursing 43 (2017) 12–22
• prevention
• control
• Catheters, Indwelling
• in-dwelling catheters
• Catheter-Associated Infection
• Catheter-Related Infection
• Intensive Care, Surgical
• Critical care
APPENDIX B
See Table B1.
Appendix C. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at
http://dx.doi.org/10.1016/j.iccn.2017.05.006.
ine data only comparison with National Healthcare Safety
Network data.
on (development of the clinical information technology
assessment tool) with

based hand rub bottles. The amount of alcohol based rub was
not quantified. The
s were half empty.
ent of CLABSI intervention compliance.
interventions of the study. No discussion of confounders.
gardBlue PLUS Multilumen CVC, antimicrobial surface coated
using Chlorhexidine,
rs)
al-impregnated catheters.
al-impregnated catheters.
ich intervention resulted in the reduction of CLABSI. Self-
reported data,
asured or discussed, no confidence intervals provided.
ed during study not clear, outcomes measurements not
correlated with study aim.
ce interval provided. Use of antibacterial-impregnated catheters.
d CVC and Intro-Flex) or CVCs impregnated with silver

platinum carbon amalgam
antimicrobial catheters)
of participants not reported. Confidence interval only reported
for one outcome.
reported or considered in the outcomes measurements, no
confounders considered.
ds of caps were used during intervention. Characteristics of
participants not
eristics of participants not reported.
en second generation antimicrobial catheter Arrow g + ard Blue
Plus antimicrobial
tion, no characteristics of participants and confounders
addressed.
orrelation between intervention and outcome not clear,
characteristics of
applied during study, no clear indication which intervention
reduced the CLABSI
measured not relevant to possible confounders of the study.

during study period. Missing data.
http://dx.doi.org/10.1016/j.iccn.2017.05.006
and C
R
A
A
A

E
E
F
F
G
H
H
J
J
K
K
eferences

dams, A., Wilson, S., 2012. The impact of using chlorhexadine
gluconate products
in the adult critical care setting. Am. J. Infect. Control 40,
e175–e176.
l-Tawfiq, J.A., Abed, M.S., Memish, Z.A., 2012. Peripherally
inserted central catheter
bloodstream infection surveillance rates in an acute care setting
in Saudi Arabia.
Ann. Saudi Med. 32, 169–173.
ntonelli, M., De Pascale, G., Ranieri, V.M., Pelaia, P., Tufano,
R., Piazza, O., et al.,
2012. Comparison of triple-lumen central venous catheters
impregnated with
silver nanoparticles (AgTive® ) vs conventional catheters in
intensive care unit
patients. J. Hosp. Infect. 82, 101–107.
arnett, A.G., Graves, N., Rosenthal, V.D., Salomao, R., Rangel-
Frausto, M.S., 2010.
Excess length of stay due to central line-associated bloodstream
infection in
intensive care units in Argentina, Brazil, and Mexico. Infect.

Running head TITLE IN ALL CAPS .docx

Running head TITLE IN ALL CAPS .docx

Recommended

Recommended

More Related Content

Similar to Running head TITLE IN ALL CAPS .docx

Similar to Running head TITLE IN ALL CAPS .docx (19)

More from jenkinsmandie

More from jenkinsmandie (20)

Recently uploaded

Recently uploaded (20)

Running head TITLE IN ALL CAPS .docx