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Journal of Nursing

Central Line Associated Bloodstream Infections

Stephanie Hopson [email protected]

Overview of Work Practice Area

Cardiac intensive care units see a lot of central lines and with these lines, comes the risk
for infections. Working in this type of unit I have seen patients with good outcomes and those
with poor outcomes and I believe that evidence-based practice can help decrease and prevent
central line-associated bloodstream infections.

Overview of Topic

A clinical problem I have noticed during my nursing practice is central line-associated
bloodstream infections. “Central line-associated bloodstream infections (CLABSIs) result in
thousands of deaths each year and billions of dollars in added costs to the U.S. healthcare
system, yet these infections are preventable (Center for Disease Control and Prevention, 2016).


Patient’s admitted to an intensive care unit (ICU) with a central line placed during
hospital admission. I chose this population because most patient’s in the ICU setting have central
lines placed due to the type of medications they are receiving. Therefore, central lines are
frequently placed, maintained, and assessed in this setting making them the greatest place for risk
of infection.


Evidence-based practice to prevent central line-associated bloodstream infections
(CLABSIs). According to the CDC, 2016, central line-associated bloodstream infections are
preventable. Maintaining sterile technique during insertion, using only sterile devices to access
catheters, and performing routine dressing changes are just a few ways to help decrease and
prevent central line infections (Smith et al., 2011).
Central Line-associated Bloodstream Infections 3


Central line-associated bloodstream infections are shown to be preventable with
evidenced-based practice. A comparison can be done on the reported number of central lineassociated
bloodstream infections before a hospital implemented using evidenced-based practice
such as, maintaining sterile technique during insertion, using only sterile devices to assess
catheters, and preforming routine dressing changes. Then looking at the number of reports after
the hospital implemented the evidence-based practice to see if there was a decrease to prevent
these infections.


The goal outcome is to see a decrease in the number of reported central line-associated
bloodstream infections over a six-month period in an intensive care unit after implementing
sterile technique during insertions, sterile devices to assess the catheters, and routine dressing
changes to prevent central line infections.


Will patients admitted to the intensive care unit with central line catheters placed during
hospital admission have lower bloodstream infections rates after six months, when sterile
technique is used during insertions, sterile devices are used to assess the catheters, and routine
dressing changes are implemented? “Nosocomial blood stream infections are one of the leading
causes of death in United States hospitals” (Smith et al., 2011, p.1038). Beside nurses that assist
with insertion, management, and care of central lines should be diligent in providing evidencebased
care that is shown to reduce and prevent nosocomial blood stream infections caused by
central line catheters.

Principle of Respect

“In the simplest form, respect for persons maintains the human beings have intrinsic and
unconditional moral worth and should always be treated as if there is nothing of greater value than
they are” (Regis University, 2015, p.1). Patients with central lines will have full autonomy over
their care, their values and desires will be addressed to do what is good for the patient, and the
patients will all receive fair treatment.

Assurance of Autonomy

Autonomy calls for the nurse to respect, support, and advocate for patients to make
decisions about their own healthcare (Quinlan-Colwell, 2013). Since this study will be focused on
patients in the intensive care unit, nurses, physicians, and families will also be involved in the
education process to ensure that even patients would are intubated and sedated are receiving
respect, support, and an advocate for their healthcare.


Beneficence is the duty to do what’s good for the patient with consideration for what the
person values and desires. Simultaneously, it encompasses duties to do no harm, to remove and
prevent harm, and to support and encourage the patient (Quinlan-Colwell, 2013). Nurses and
physicians have the duty to intervene and report when they see that sterile technique is broken
during insertion, sterile devices are not used to access lines, and routine dressing changes are not
completed. Patients will be informed of all risks and benefits of central lines and the steps being
taken to decrease the risk for blood stream infection.


Justine is the right to a just and fair treatment. Clients need to be treated in a manner that
they deserve (Quinlan-Colwell, 2013). Fairness requires that we treat people in equal situation in
Central Line-associated Bloodstream Infections 5
an equal manner. All patients, regardless of diagnosis or potential outcome will received the same
interventions to prevent their risk for exposure to bloodstream infections.
The NIH Protecting Human Research Participants certification can help me carry out
autonomy, beneficence and justice to participants. The certification provides education on the U.S.
Department of Health and Human Services (HHS) regulatory and NIH policy requirements. I know
have a better understanding of the history and importance of human subject’s protections, risks
that the project might post to participants, and how to minimize these risks.

Quantitative Study One

For the study a community based medical center developed a central line bundle to
reduce catheter related blood stream infections (CRBSI). “The innovative combination of
focused nursing practice and product technologies were selected for the bundle and implemented
through a defined educational program” (Harnage, 2017, p.218). From January 2006 thru March
2007 there were zero occurrences of CRBI (Harnage, 2017). During this 15-month period the
PICC insertions increased by 103%. (Harnage, 2017).

Type of Study

Sutter Roseville Medical center used an experimental design which provided the best
evidence for claiming that a cause-and-effect relationship exist (Schmidt, 2015). Sutter Roseville
Medical Center reported eleven occurrences of CRBSIs in 2005 (a twelve-month period) prior to
the central line bundle implementation. After implanting the central line bundle the results
showed the interventions had a direct effect on the outcome. There was no reported catheter
related blood stream infection in fifteen months (Harnage, 2017).

Threats to Internal and External Validity

A couple internal and external validity exist within this qualitative study. External threat
would include the selection of brand of product used. The specific products used at Sutter
Roseville Medical Center may not be the same at another facility implanting this bundle and
could affect on the outcome. An internal threat may be the education provided to the health care
team inserting central lines. This community hospital had a PICC team trained on the central line
bundle which was successful. Other facilities may have larger or just several different
departments that would need to be trained on the bundle which could affect outcome. Teaching
facilities have multiple different students performing central line insertions and it may be
difficult to ensure all students are trained on the bundle.


The quantitative study shows that a multimodality bundle, combining nursing practice
interventions and technology can successfully decrease the incidence of CRBI. The evidenced
based practice project goal is to reduce central line associated blood stream infections. With the
outcomes of the quantitative study having zero CRBIs in 15-month, their innovated bundle is a
great resource for this evidenced based practice project. “While some of the bundle components
have not been widely researched and instead are based on theory and accepted clinical practice,
the early outcome provides a basis for additional study and refinement” (Harnage, 2017, p.218).
This quantitative study data was collected from thirty-two critical care beds which is the same
target population for this evidenced based practice project.

Quantitative Study Two

A Canadian, medical-surgical, pediatric intensive care unit did a study to determine the
incidence of catheter-associated blood stream infections (CA-BSI) pre- and post-introduction of
a CA-BSI bundle. The bundle was adapted for pediatrics and included components for catheter
insertion and ongoing catheter maintenance (Sharar et al., 2008).

Type of Study

A medical-surgical pediatric intensive care unit (PICU) used an experimental design
which provided the best evidence for claiming that a cause-and-effect relationship exist
(Schmidt, 2015). This Canadian PICU had a decreased infection rate per 1000-line days
decreased from 8.8 to 1.8 (Sharar et al., 2008). After implantation of the catheter-associated
blood stream infection (CA-BSI) bundle decreases per 1000 admission were also seen, from 18.3
to 5.1.

Threats to Internal and External Validity

Similar threats from the first qualitative study exist within this qualitative study. External
threat would include the population of patients seen. Adults hold a much higher percentage of
admissions to intensive care units then pediatrics. Therefore, the group used within this study is a
small group. An internal threat may be the education provided to the health care team inserting
central lines. The Canadian PICU at a target population for testing and education consisting of
the intensive care unit attending and fellowship physicians and the pediatric critical care nurses
(Sharar et al., 2008). This facility is like the facility being used in this evidence based practice
project because it is a teaching facility associated with a university.


The study showed that education and institution of a bundle decreases CA-BSI. The CABSI
bundle was adapted for pediatrics and included components for catheter insertion and
ongoing catheter maintenance (Sharar et al., 2008). The population in this study is pediatric and
the population for this evidence based project is adults. However, both groups were admitted to
intensive care units and therefore the interventions may still result with similar outcomes.

Qualitative Study One

Two regional university-affiliated hospitals did a study to identify the clinical
characteristics and outcomes of peripheral vascular catheter-related bloodstream infections and
determine the risk of severe complications or death (Akihiro et al., 2017).

Type of Study

Retrospective observational case study at two regional university-affiliated hospitals
which studied the clinical manifestations, underlying diseases, laboratory results, treatment
methods, recurrence rates, and complications in 62 hospitalized patients diagnosed with
peripheral vascular catheter-related bloodstream infections by positive blood cultures (Akihiro et
al., 2017).

Credibility, Confirmability, Dependability, and Transferability

This study was approved by the Tokyo Medical University ethical committee (Akihiro et
al., 2017). “Written informed consent was obtained from all subjects for the publication of this
report and accompanying images” (Akihiro et al., 2017, p.6). The authors declared that they have
no competing interests and there was no funding for this study (Akihiro et al., 2017).


This qualitative study is applicable to evidence based practice on catheter-associated
blood stream infection since it addresses risks of severe complications or death. “The two
regional hospitals observed cases of severe peripheral vascular catheter-related bloodstream
infections requiring intensive and long-term care along with lengthy durations of antibiotic
treatment due to hematogenous complications, and some patients died” (Akrihiro et al., 2017,
p.1). This study gives details on the outcomes catheter-associated bloodstream infections can
have and thus how important prevention is.

Qualitative Study Two

Samsun Education and Training Hospital conducted a study to investigate the
characteristics and the risk factors for mortality in patients with central line-associated blood
stream infections (CLABSIs) in the intensive care units (ICUs) and provide the relevant data
(Atilla et al., 2017).

Type of Study

Samsun Education and Training Hospital conducted a case study in which ICU patients
were screened to identify patients with CLABSIs hospitalized from January 2008 through July
2013 (Atilla et al., 2017). “A total of 166 CLABSI episodes in 158 patients out of 17,553 on
38,562 catheter and 94,512 hospitalization days were evaluated” (Atilla et al., 2017).

Credibility, Confirmability, Dependability, and Transferability

The article doesn’t mention much except affiliations with the Department of Infectious
Disease and Clinical Microbiology, Department of Anesthesiology and Reanimation, and
Department of Internal Medicine at Samsun Training and Research Hospital in Samsun, Turkey
(Atilla et al., 2017).


Samsun Education and Training Hospital showed that infection developed in catheterized
patients at a median of 14 days, and the highest infection rate with 13.4% was the femoral region
among the places where the catheter was inserted (Atilla et al., 2017). This study shows that
placement of femoral central line catheters puts patients at a higher risk for catheter associated
blood stream infection which directly affects intensive care unit patients in need of central line

Ranking the Evidence

Practice Recommendations

Practice recommendation one is to avoid placement of central line catheters into femoral
area. Studies have shown that placement of femoral central line catheters puts patients at a higher
risk for catheter associated blood stream infections (Atilla et al., 2017). Therefore, the femoral
area should be avoided unless two unsuccessful attempts have been in intrajugular placement or
presents of blood clots is noted. This evidence is from well performed and high-quality studies
and is strongly recommended based on the outcomes being achieved from this study. This
recommendation is ranked AI.

Practice recommendation two is to create a bundle for insertion and maintenance of
central line catheters. One of the studies researched showed a decrease in catheter-associated
blood stream infections after the implementation of a bundle (Sharar et al., 2008). Since there is
limited information on what the bundle consisted of in the study, more research will need to be
done to know what steps should be used in the bundle to decrease CLABSIs. There is a
moderate/ low level of evidence in this research paper on what should be included in a bundle.

However, because studies have shown that bundles aid in compliance among health care workers
this recommendation is ranked BIIa.

Key Stakeholders

Hospital staff, including physicians, nurses, and administrators are key stakeholders.
Patients are the other key stakeholder for this project.

Engagement Strategies

Physicians and nurses that are key stakeholders for this project will be educated on the
reasons for the study, as well as expected outcomes. This education should engage the staff
enough to want to improve patient outcomes. Patients will be educated prior to insertion on the
risks and benefits of central line placement. Patients will continue to be educated daily on
maintenance of their central line. This will engage patients and give them autonomy over their

Resistance Strategies

Physicians and nurses may be resistance to adapting a central line bundle kit. Training
and learning new technique/ equipment takes time. If resistance occurs the staff members will be
met will to discuss challenges they are having and reasons for their resistance. Patients are not
typically the stakeholders that will causes resistance since this bundle will help to reduce their
risk of infection and therefore provide them with better health outcomes.


During the education process the healthcare team will be asked about any challenges they
see potentially arising during the implementation process. Knowing what barriers and resistance
could occur in advance could prevent problems after implementation. This evaluation would take
place within the first month of the education. As central line catheters are placed, patients will be
monitored for infections. If an infection occurs, the physician who inserted and the nurses who
have been maintaining the line will be notified. Once notified they will be asked what they’re
thought are on the reason for the infection and possible changes that could be made to prevent
other patients from developing infections. This evaluation will be ongoing but initially will begin
the moment a patient is diagnosed with a central line-associated blood stream infection.


Akihiro, S., Itaru, N., Hiroaki, F., Ayaka, T., Takehito, K., Shinji, F., Matsumoto, T. (2017).
Peripheral venous catheter-related bloodstream infection is associated with severe
complications and potential death: a retrospective observational study. BMC Infectious
Diseases, 171-6. doi:10.1186/s12879-017-2536-0
Attill, A., Doganay, Z., Celik, H. K., Demirag, M. D., & Kilic, S. S. (2017). Central lineassociated
blood stream infections: characteristics and risk factors for morality over a
5.5-year period. Turkish Journal of Medical Sciences, 47(2), 646-652. doi:10.3906/sag1511-29
Center for Disease Control and Prevention [CDC]. (2016). Central Line-associated Bloodstream
Infection (CLABSI). Retrieved from:
Harnage, S. (2007). Achieving zero catheter related blood stream infections: 15 months success
in a community based medical center. Journal Of The Association For Vascular Access,
12(4), 218-224.
Quinlan-Colwell, A. (2013). Making an ethical plan for treating patients in pain. Nursing,
43(10), 64-68.
Regis University. (2015). Ethics at a glance. Retrieved from:
Schmidt, N. A. (2015). Evidence-Based Practice for Nurses, 3rd Edition. [Bookshelf Online].
Retrieved from:
Central Line-associated Bloodstream Infections 14
Sharar, Z., Northway, T., Skippen, P., Braun, L., Krahn, G., Kissoon, N., & Milner, R. (2008).
Reducing catheter-associated blood stream infections in a pediatric intensive care unit: a
collaborative effort. Journal of Patient Safety, 4(4), 221-226.
Smith, J., Egger, M., Franklin, G., Harbrecht, B., & Richardson, J. (2011). Central lineassociated
blood stream infection in critically ill trauma patient. American Surgeon,
77(8), 1038-1042.

Appendix A

National Institutes of Health Protecting Human Research Participants Certificate

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