CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS2CENTRAL LINE-ASS.docx

CENTRAL LINE-ASSOCIATED BLOODSTREAM
INFECTIONS2
CENTRAL LINE-ASSOCIATED BLOODSTREAM
INFECTIONS2
Central Line-Associated Bloodstream Infections Literature
Review
Kerry S. Murphy
Grand Canyon University
Translational Research and Evidence-Based Practice
DNP-820-O501
Dr. Kari Lane
September 26, 2018
Running head: CENTRAL LINE-ASSOCIATED
BLOODSTREAM INFECTIONS2
Central Line-Associated Bloodstream Infections Literature
ReviewComment by Microsoft Office User: The heading of
introduction is inferred in APA format
I. Introduction
Central Line-Associated Bloodstream Infection (CLABSIs) in a
fatal infection that results from bacteria or viruses entering the
bloodstream through the central line. A central line, also known

as a central venous catheter, refers to a tube used by doctors to
administer medication, fluids or to collect blood from the body
of a patient (Deason & Gray, 2018). Central Line-Associated
Bloodstream Infection is one of the leading causes of deaths
each year in different countries across the globe. Central Line-
Associated Bloodstream Infection has been an area of interest
for many healthcare researchers representing a diverse body of
knowledge about the infection while still expanding on what is
already known. The paper is an analysis of articles related to
CLABSIs with the major themes of concern to the authors
including risk factors, interventions, CLABSIs and Hospital
Acquired Infections (HAIs), benefits of the preventive measures
and the common symptoms of CLABSIs. Comment by Microsoft
Office User: Add a description of how the literature search was
completed. Tell the reader how you did your literature search,
which databases you searched, how many articles were found,
and how you eliminated articles to come to the ones you
included here.
II. Questions Posed in the Studies
a. Afonso, Blot, & Blot (2016) seeks to establish how hospital-
acquired bloodstream infections can be prevented through the
use of chlorhexidine gluconate-impregnated washcloth bathing
in intensive care units. In the study by Chidambaram (2015), the
question raised is, what associations dental procedure and CVCs
have.
b. Kadium, M. (2015) inquired into how the education program
for 1 month, based on the
evidence-based guidelines recommended by CDC, will improve
registered dialysis nurses’ knowledge regarding CVC
maintenance care?
c. CDC and NCBI (2011) raise the research question, how many
people have been affected in the USA from 2001-2009?
d. Srinivasan, Wise, Bell, Cardo,Edwards, Fridkin, Jernigan,
Kallen, McDonald, & Patel (2011) considers questioning the
perception of central line-associated bloodstream infection.
e. Dougherty (2012) questions the potential solutions in

reducing incidences of central-line associated bloodstream
infections have to be created in line with the clinical setting and
careful consideration of the patients and the organizational
culture.
f. Lin, Apisarnthanarak, Jaggi, Harrington, Morikane, Thu,
Ching, Villanueva, Zong, Jeong, & Lee, (2015 (2011) the
inquiry is into what level of knowledge, attitudes, and behavior
the nurses in the cancer setting in the Italian hospitals have
about CVC procedures.
g. O’Grady, Alexander, Burns, Delilnger, Garland, Heard,
Lipsett, Masur, Mermel, Pearson, Raad, Randolph, Rupp, &
Saint (2011), the inquiry focused into how Positive blood
culture shows the relationship between CLABSI and CDC
surveillance.
h. Perin, Erdmann, Higashi, Sasso, Bianco et al. (2016) the
research question is; What are the CLABSI-related preventive
measures implemented among adult patients hospitalized in an
ICU?
i. Esposito, Guillari & Angelillo (2017) inquiries into what
level of knowledge, attitudes, and behavior the nurses in the
cancer setting in the Italian hospitals have about CVC
procedures. It also questions the predisposing factors for the
knowledge, attitudes, and behavior.
j. Oliveira, Stipp, Silva, Frederico, & Duarte (2016) questions
into the standard procedure in the ICU, the catheterization of a
central venous access good care practices from insertion and
handling to the moment of withdrawal.
k. In a research by Basinger, M. A. (2014), the research
question questions into the causal effects of the CUSP on the
reduction of CLABSIs within the relationship CUSP team
member webinar attendance has with the reduction of CLASBIs.
l. Xu & Wu (2017) inquire about how a Comprehensive Unit-
Based Safety Program which involves the improvement of
communication, teamwork, and safety in the ICUs.
m. Bianco, Coscarelli, Nobile, Pileggi, & Pavia (2013) find it
interesting to establish the role of knowledge, evidence-based

practices, the insertion and maintenance of CVC with the
protection of CLABSIs.
n. The Final research is by Han, Liang, & Marschall, (2010),
who question how the involvement of education to the family
and the patient can help prevent CLABSIs attacks among
patients on CVC care. Another study by questions the
relationships between Positive blood culture and CLABSI with
CDC.Comment by Microsoft Office User: Synthesize each
section by describing articles with commonalities and
differences. But you need to write in paper format in paragraph
form.
III. Identified SubthemesComment by Microsoft Office User:
No longer use an outline, use headings (according to APA
format) for your main concepts, and place your subthemes
underneath, as described in your 10 Strategic Points document
With the picot question In Patients > 65 years of age with
central line catheters, how does staff training of key personnel
and reinforcement of central line catheter hub hygiene after its
insertion, along with the apt cleansing of the insertion site,
reduce the incidence of CLABSIs (Central Line Associated
Blood-stream Infections) compared to standard care over a one-
month period at ICU Regional Medical Center, Texas? From
this, there are various subthemes that emerge in this study.
These include; the issue of hygiene and its effect on CLABSI,
knowledge and how it impacts on infection, policies or
experience and how it affects perception and prevention of
infections, evidence-based practice, non-evidence-based
practice, disinfection and sterilization, Insertion bundle,
Maintenance bundle, and Quality Improvement.Comment by
Microsoft Office User: First this isn’t a PICOT question
Second you need to synthesize this information describe
multiple articles at once
So discuss CLABSI the subthemes under CLABSI would
include
Hygiene and impact

Knowledge
Policies
Nurse experience
Evidence Based Practices/Interventions
Describe in full
The reviewed literature has shown that the nurse, patients,
family, and evidence versus non-evidence-based practice are
important in the analysis of the situation. Besides, the setting,
type of catheter, and conditions affect the entire discussion.
IV. Risk Factors Associated with CLABSIs
a. Contamination on Insertion
The catheter may gain entry into the bloodstream during the
insertion of the line into the body of the patient. The rate of
infections during insertion is substantially dependent on the
hygiene levels that are put in place by the health care providers
(Dick et al., 2015). The rates of infection during insertion
happen to be high showing ignorance or lack of professionalism
among the health caregivers. Contamination during insertion
may also result from the instruments used and how sterilized
they are.
b. Contaminated Skin of the Patient
The insertion is done on the body of the patient. A contaminated
skin of the patient may contain germs which may enter the body
during the insertion (Dombecki et al., 2017). The fact that
patients have negligible knowledge concerning the different
ways the infection may occur means that there is so much
responsibility placed on the health caregivers. The infection
rates due to unsanitary practices of the patients seem to have
drawn the attention of the authors of the different articles
analyzed. With the rates of CLABSIs rising each year, mortality
rates have also increased. Researchers have made CLABSIs
prevention a priority to address such risk factors to avoid or
reduce infection rates.
c. Non-Compliance with the Central Line Maintenance
There are guidelines for healthcare professionals meant to

reduce the chances of CLABSIs infection. Such guidelines
include not using antiseptics and ensuring complete dressing
changes (Orwoll et al., 2018). As much as these guidelines and
policies are in place does not mean that compliance is definite.
Cases of caregivers who do not comply with the stipulated
guidelines are common and such levels of unprofessionalism
have cost patients their lives.
V. Interventions
a. Removal of Unnecessary Lines
The authors agree that there are times patients will have lines
which are no longer being used for any medical purpose. These
are mainly patients who have spent so much time in the
hospitals, and the chances of being discharged seem minimal
(Sodek, 2016). The caregivers are meant to remove lines once
they have served the purpose. The more these lines remain on
the body of the patients the more the chances of infection.
Bacteria and all other associated germs will easily enter the
body.
b. Health Care Providers to Follow Recommendations
Healthcare professionals are trained on the best practices that
are meant to ensure that the chances of patient infections are
minimized or even eliminated entirely. Unfamiliarity creeps in
at times, and the well-being of the patients is jeopardized
(Stone et al., 2014). Just like any other profession, health care
ties the professionals around practices which ensure ethical
undertakings to safeguard the lives of the patients. The authors
are for the idea that health care professionals should be just to
patients and do what their work ethics dictates them to do. Such
will ensure improved health and safety of the patients.
c. Encouraging Teamwork
In any health care setting, there are two main participants.
These are the health caregivers and the patients. One of the
authors suggests that teamwork between these two parties will
go a long way in reducing the rates of these infections (Stone et
al., 2014). Teamwork will ensure that there is knowledge
sharing, that key concerns and risks that may be known to one

of the parties are made known to the other. The impact
teamwork will have towards preventing the cases of CLABSIs
in hospitals is immeasurable. The same should be embraced and
upheld.
VI. CLABSIs associated infections/Transmissions
a. Hematogenous Transmission
This is an infection that is characterized by a primary tumor
penetrating into blood vessels. They then get transported in the
blood vessels and eventually into the distant parts of the body
of the patient (Stone et al., 2014). Once at the distant sites, the
cells will penetrate the walls of the vessels again and build a
basis for another, a new tumor on the new site. Such are the
same cases that happen with CLABSIs. Examples include
catheter-associated Urinary Tract Infections (CAUTI) that can
lead to CLABSI’s.
b. Catheter-associated Urinary Tract Infections (CAUTI)
A urinary tract infection (UTI) refers to an infection in any part
of the urinary system. UTIs are also common healthcare-
associated infections reported by both patients and healthcare
givers. These infections are associated with urinary catheters, a
tube which is used by doctors through the urethra to drain urine
(Douglas, 2015). Most of the hospitalized patients end up with
urinary catheters inserted in their bladder. Prolonged use of the
catheters increases the risks of the infections. Health caregivers
should ensure that these catheters are removed when not being
used to reduce the risk of patients contracting the CLABSIs.
c. Contaminated Infusates
The term refers to the introduction of pathogens into the body
of patients. The introduction of these pathogens occurs through
the sterile used by the health care providers. During surgery or
during other procedures which may require line insertion,
bacteria may be introduced into the body of the patient (Stone et
al., 2014). Contaminated infusates happen to be one of the ways
CLABSIs bacteria is introduced into the bloodstream. Patients
and the health care providers need to be educated on such risks.
VII. Necessity for Interventions

a. Reduced incidences of CLABSIs
The preventive measures mentioned above by the authors of the
different articles will go a long way into reducing the incidents
that are reported by patients and caregivers concerning
CLABSIs (Klintworth et al., 2014). Encouraging adherence to
the hygiene standards, the policies and the recommendations as
they relate to CLABSIs infections will enable the creation of an
environment that will enhance the well-being of the patients and
also minimize the chances of contraction of the infections. The
infection is deadly and is already costing patients and nations
dearly.
b. Reduced morbidity
Morbidity has been defined as how often a disease occurs or is
reported in a population. The morbidity rate is determined by
examining the number of patients with a certain disease at a
given period (Kim & Biorn, 2017). Reduced cases of a disease
mean that preventive and treatment measures are effectively
implemented by all stakeholders involved. CLABSIs infections
are no exceptions here. The literature work of the previous
authors appreciates that the health care institutions that have
adopted the interventions measures above report few and
reduced cases of the infection.
VIII. CLABSIs Symptoms
a. Site Discharge
The area where the catheter is placed should remain dry, and no
discharge should be coming from the area. Some patients,
however, may notice yellow or green discharge (Conley et al.,
2018). The drainage should be a cause for alarm, and the
authors have identified the discharges as some of the top
indicators that something has gone wrong and healthcare
providers should act up. Discharges show that the area is not
fresh and has been exposed to bacteria and germs, something
that should be of great concern.
b. Site Swelling
Patients may experience additional swelling at the place where
the catheter line has been inserted. The swelling is an indicator

that there is no healing that is taking place and that there is
every reason to worry about the well-being of the patient
(Castagna et al., 2016). The authors suggest that nurses should
give attention to the recovery process of patients and ensure
that such instances are noted and addressed. In cases where
there is no close relationship between the health caregivers and
the patients, such incidents may be hard to notice, and the
patients end up suffering and worse still, be exposed to the ugly
infection which may even cost them their lives.
c. Site Redness
A patient may develop red streaks at the area where the line has
been inserted. Another warning sign that the patient may be
headed to a CLABSIs. Again, if there is no close interaction
between patients and their caregivers such may be hard to
notice (Chesshyre et al., 2015). Worse still if the patient is not
aware that such are causes for alarm. They may never report the
same and end up risking their lives. Adult patients and children
are at the greatest risk of these symptoms because in most cases
they do not know what should be made known to the health care
providers and what should not be a cause for worry.
IX. Research Questions
a. How does the training of health-care providers on the risks
and the preventive measures of CLABSIs impact the overall
infection rates?
b. What is the level of knowledge of nurses regarding the use of
evidence-based guidelines to prevent central venous catheter
bloodstream infections?
c. Does an increase in nurse’s knowledge concerning CLABSIs
infections reduce the number of infections in the Intensive Care
Units?
X. Sample Populations
The authors have utilized different study populations to
accomplish their objectives. The two major categories of
respondents that are common to all authors are healthcare
professionals and adult patients suffering from or who have
suffered the CLABSIs infections in the past (Hsu et al., 2014).

These two categories have a rich knowledge on the study topic.
Such enables researchers to collect adequate data for their
research topics and also draw logical conclusions.
There are several processes through which people sample
information in studies. For Alfonso et al. (2016) the search of
the various database using key terms gave 291 records,
however, based on relevance only 4 articles were suitable for
the study. In a study by Dougherty, there was convenience
sampling of a population of registered nurses in the LTACH
setting after completion of orientation to the unit. Out of 52
eligible nurses, 31 participated in the survey response. The
study by Lin et al (2015) utilized a cross-sectional design in the
qualitative analysis of sources based on the key concepts of the
study. Moreover, O’Grady et al. (2011) used data from a variety
of available studies. Perin et al. (2016) explored a purposive
sampling and selection of 34 studies that formed a set through
which to assess results after a systematic review of academic
and health database. In the sampling process, Esposito (2017)
utilized a cross-sectional design in 16 non-teaching and
teaching public and private hospitals with units utilizing CVCs
for oncological patients. The target group was 472 nurses in the
oncology and outpatient chemotherapy units of the selected
hospitals. Likewise, Oliveria et al (2016) samples were
collected through a cross-sectional study with questionnaires to
76 professionals in the intensive care. Zu & Wu (2017) utilized
the qualitative process and a systematic search of databased on
CINAHL, ABI INFORM, and OVID through which they
established more than a hundred articles before applying the
exclusion-inclusion criteria and utilizing ten articles in the
study. Han et al (2010) searched from a variety of available
studies for healthcare workers in all units using CVCs in the
Calabria region of Italy. Bianco et al. (2013) used samples from
a number of CLABSIs which were collected by the hospital-
based IP in line with the NHAN approach and definition of
CLABIs. The CUSP teams of hospitals receive monthly
feedback on infections and quarterly feedback on rates of

infection per 1,000 catheter days. Basinger (2016) samples were
collected through a cross-sectional study with questionnaires to
76 professionals in the intensive care. In another study by
Chidambaram (2015) the samples used were acquired from
existent studies. On the other hand, Kadium (2015) utilized a
convenience sampling of registered dialysis nurses in the
hemodialysis unit was used in a pre and post-test educational
interventional design among 60 registered dialysis nurses. CDC
and NCBI (2011) worked by using the patients aged 1 year and
above in the inpatient, outpatient and ICU settings. The
acquisition of the participants was through Fistula First
breakthrough initiative. Finally, Srinivasan, et al. (2011) used
the ICU, inpatient ward, and hemodialysis facility records for
years 2007, 2009 and 2001 to establish the rates of
infection.Comment by Microsoft Office User: Excessively long
paragraph
Participants should describe more than numbers
Age, gender, marital status (i.e. demographic variables to
describe the sample) so that you know if your population
matches those in these studies
XI. Limitations
There are several obvious limitations in the studies held before.
For example, Esposito et al. (2017) opine that self-reported
questionnaires affected accuracy in response. Questionnaires
ought to be anonymous to encourage correct reporting. He also
notes that a cross-sectional study hindered establishing a
causative relationship with outcomes of interest. Future studies
need to focus on non-evidence-based practices and dressing of
catheters and how they relate with CLABSI (Han et al., 2013).
Also, the study by Basinger (2014) was limited by failure to
separate the efforts that aim at improving the use of CUSP,
related approaches, and technologies that reduce
compliance.Comment by Microsoft Office User: Describe the
limitations that you determined with each study. The limitations
they state are obvious what did the authors miss?
In the study by Afonso et al. (2015) the limitation was in the

use of cumulative analysis on line-associated HABSI types
while reporting the catheter culture is a diagnosis of infection.
Moreover, another study by Lin et al. (2015) showed that the
limited time and consideration of barrier towards quality, an
aspect that needed adequate time hindered acquisition of enough
information. Furthermore, Perin et al. (2016) note that the use
of one type of catheter hindered generalization of information to
other health departments.
Chidambaram (2015) assert that the limited evidence and
utilization of exploratory method when conducting a study on
CLABSIs. According to Kadium (2015) the small sample size
and short duration within which it was conducted limited the
results that were acquired. Another problem emerged because
there was no assessment of the learning styles of the patients.
CDC and NCBI (2011) states that even though there has been a
reduction in the infections of CVC users, there is a need for
more solutions to preventing this According to Srinivasan et al.
(2011), there is a need for continuous studies on CLABSIs as
they enhance establishing the preventive mechanism.
XII. the Conclusions and recommendations
Overall, there are various issues that are addressed in the
various papers in this analysis. From the literature review
Afonso et al. (2016) conclude that hospitals achieve zero
infections of CLABSI rates meaning the continued usage of
surveillance together with a washcloth bathing for they curtail
Gram-positive bacteria. Thus, hospitals with high baseline
hygienic standards of care and lower CLABSI rates might
benefit less from CHG washcloth bathing. Additionally, Lin et
al. (2015) note that the adherence to the current evidence-based
practice guidelines, education, and consideration or compliance
to hygiene, and use of chlorhexidine antiseptic bathing instead
of the soap helps in the prevention of CLABSIs. For example,
according to O’Grady et al. (2011), maximal sterile, cautious
insertion of catheters, avoidance of routine catheter
replacement, usage of the antiseptic/antibiotic impregnated
short-term central venous catheters and chlorhexidine-

impregnated sponge dressings help to prevent and manage
CLABSIs.
Similarly, Perin et al., (2016) opine that the consideration of
necessary interventions on the catheters can prevent infections.
According to Esposito et al. (2017) in situations where nurses
have a positive attitude, and perceive hygiene as a risk in
CLABSIs as well as where evidence-based practice programs
are used, infection is likely to be prevented. There is still a low
adherence to handwashing. Xu & Wu (2017) note that patient
cooperation and knowledge of proper care for CVC prevent
infections. There is a need for studying practical clinical nurse
interventions in the care for CVC. In the study by Han et al
(2013) state that blood culture is necessary for managing CVC
patients. Formal training, years of experience, written policies,
enhance compliance to proper CVC care and reduce infections
(Han et al., 2013). In a study by Bianco et al. (2013), there is a
conclusion that less costly evidence-based education, CUSP
prevent infections. It is also indicated that multidisciplinary
education programs improve assistance to patients (Oliveira et
al., 2016)
According to Afonso et al. (2016), an analysis into the topic
requires separate primary, secondary and central line-associated
HABSI types in reporting catheter culture during the diagnosis
of bloodstream infection that increases certainty and lowering
of risks of bias as a result of improper attribution of blood
culture contaminants.
Furthermore, Dougherty, (2012) suggests that in future research
there is a need for an investigation into the personal motivation
in adherence to the clinical practice guidelines of CVC care.
Further examination into the required time, barriers towards
quality care. Another important area of analysis is the LTACH
specific practice in the assessment of CLABSI and prevention
strategies towards CVC infections (Dougherty, 2012).
In the study by Chidambaram (2015), the conclusive view offers
that the dental care process is necessary for pediatric CKD
patients if studies on CVC are being held. Besides, CVC

benefits CKD patients but poses a threat for long-term
candidates due to negligence on disinfection and sterilization
processes. According to Kadium (2015), high education levels
do not affect pretest, but the completion of infection control
course affects pretest scores. Another argument is that
evidence-based care allows students to work purposefully.
Moreover, the provision of continuous education enhanced
retention and application of knowledge in tasks. In another
study by CDC and NCBI (2011), it is indicated that while 2009
has about 25000 (58%reduction) fewer than 2001 but substantial
numbers of infections caused by Staphylococcus aureus
continue to exist. Ultimately, Srinivasan et al. (2011) opines
that HAI best practices help prevent CLABSI cases. It is thus
necessary for future studies to focus on more than one type of
catheter for results to be relevant to various departments of
health.
From the above literature review, it is clear that evidence-based
practice, policies, hygiene, education and attendance of
workshops are important aspects that need to be studied.
Besides, the consideration of study population, using the
adequate time for the study, having confidential questionnaires
are part of the essentials of conducting a useful study on CVCs
and CLABSI’s.
The conclusions and recommendations are drawn from what the
authors had from their results. There is the need for continued
monitoring and feedback concerning compliance with the set
hygiene practices aimed at preventing CLABSIs infections. The
infection basics, such as patient and health care providers’
education, should be addressed (Beverly et al., 2018). Public
health funding has also been suggested as a recommendation
towards the prevention of the infection. Further areas of the
study should address different ways of tracking infections,
whether they are high at the emergency rooms or the operation
rooms. The areas for further research should also focus on
strategies aimed at removing barriers in policies and practices.

Comment by Microsoft Office User: Many APA errors need
correct on your reference pages
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anticipated graduation date
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