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Running Head: REDUCING THE INCIDENCE OF CENTRAL LINE INFECTIONS

Reducing the Incidence of Central Line Infections

Ferris State University
Maria Licari

Running Head: REDUCING THE INCIDENCE OF CENTRAL LINE INFECTIONS

Abstract
The purpose of this paper is to form a clinical question in PICO format, and conduct research on
a nursing skill and gather knowledge from nursing research only, on that subject. After reviewing
the research a nurse must come to a conclusion whether there is substantial research to support
the practice. This paper is supported by articles from peer reviewed journals that look at the
clinical problem of central line associated blood-stream infections (CLABSIs) and current
methods used to eliminate or reduce these infections. Three article critiques focus on two
methods specifically, scrubbing the access port with an alcohol swab and an alcohol impregnated
luer lock cap. Finally this paper takes in all the information gathered and relates these methods
to nursing and their impact on nursing knowledge, skills, and attitudes.

Running Head: REDUCING THE INCIDENCE OF CENTRAL LINE INFECTIONS

Reducing the Incidence of Central Line Infections
Nursing students are exposed to different situations in the clinical setting, and some may
ask the reasoning behind skills and tasks they perform each day. Patient safety is a concern that
will follow nurses throughout their career and research is constantly searching for ways to
improve patient quality and safety while maintaining the ease of nursing care to implement these
changes. The purpose of this paper is to look at a fundamental nursing skill, write a question,
and then review research, and determine if this is a well-supported practice or if there should be
more research done before implementing change.
Clinical Question
According to the CDC (2014), an estimated 41,000 central line-associated bloodstream
infections (CLABSIs) occur in U.S. hospitals each year (CDC, 4-1). CLABSIs are serious
infections usually due to improper health care worker manipulation of the device, and can result
in increased hospital stay and in some cases, death. The study represented in the American
Journal of Infection Control written by Guerin, Wagner, Rains, and Bessesen (2010), noted that
the average dwell time between insertion and infection was about 12 dayswhich led us to
suspect that events occurring after insertion might be responsible for the infections(Guerin,
Wagner, Rains, & Bessesen 2010). This supports the need for nursing research because research
shows infection is occurring during manipulation of the ports by nursing staff.
Needless systems have not always been used. The implementation of needless systems
removed the risk for needle stick injury but brought forward more problems with CLABSI. In
one study done by Karen Charron (2012), the antimicrobial luer lock implemented with scrub
the hub for 15 seconds reduced the incidence of CLABSI from 1.54 CLABSIs/1000 catheter

Running Head: REDUCING THE INCIDENCE OF CENTRAL LINE INFECTIONS

days to 0.58 CLABSI/1000 catheter days (Charron, 373). Another study done in Denver,
Colorado looked at already implemented central lines and needless access ports and their
associated care bundle. The study looked at the techniques and the care nurses provide when
accessing a central line after a 4 hour hands-on training class. The primary method of cleansing
of the port was washing hands before access and scrubbing the hub with an alcohol pad for 15
seconds. The results showed a significant drop in CLABSI after the 4 hour hands-on training
class that reinforced hand washing and scrubbing. But this brings up the question of how well
this method will work later when nurses become more time restrained and go back to old habits.
Through experience during clinical hours the use of alcohol impregnated caps became the
method of choice in preventing blood stream infections in central lines. The question posed is if
an alcohol impregnated cap on the access ports is more efficient at reducing CLABSI than
relying on nursing compliance to scrubbing the hub for 15-30 seconds before each access.
Methodology
The formulation of a PICO question began with clinical observation of the use of Curo brand
alcohol impregnated caps on all central line access ports in the hospital setting. Nursing students
are currently taught to scrub the hub for 15-30 seconds before accessing a port. Curiosity
formed the question of what is more effective, scrubbing the hub or the use of these alcohol
impregnated caps.
The databases used to find research were CINAHL and PubMed. The keywords CLABSI,
Central Line, Alcohol, Alcohol Impregnated Caps and Caps were used to focus
searches. Results rendered via CINAHL and PubMed were around 60 and narrowed further with
the use of limits. The limits used were articles published within the last 5 years, and within

Running Head: REDUCING THE INCIDENCE OF CENTRAL LINE INFECTIONS

CINAHL the any author is a nurse option was chosen. The levels of evidence found did not
exceed level B by AACN standards (Armola et al., 2009), however, systematic reviews may
come out in the future. The current systematic reviews found focused more on the technique of
insertion, type of catheter used, and sterile technique during insertion rather than the care done
after insertion which pertains mostly to nurses.
Nursing research was the only research used to answer the clinical question because nurses
are the most frequent caregivers to access these ports. A nursing student can relate better to
nursing research and their explanation of why these skills are done the way they are. Nurses are
also best at conducting research on tasks they do themselves, because they think of the question
first since they are the ones exposed to the situation.
Discussion of Literature
Article 1
The peer reviewed journal, American Journal of Infection Control released the article
Continuous Passive Disinfection of Catheter Hubs Prevents Contamination and Bloodstream
Infection written by authors including doctors and nurses that are looking at the effectiveness of
an alcohol impregnated cap in preventing contamination or infection. According to AACN
standards, this article falls under level D on the new evidence leveling system (Armola et
al.,2009). The researchers narrowed down that infections occurred either extraluminally or
intraluminally and found through other studies the use of alcohol impregnated caps were
effective (Wright et al., 2013). These other studies were low evidence based practice and
supported the need for this study to be done. The purpose of this study is to see how effective
the implementation of an alcohol impregnated cap is at reducing intraluminal bacterial CLABSIs
(Wright et al., 2013).

Running Head: REDUCING THE INCIDENCE OF CENTRAL LINE INFECTIONS

The population was sampled from a 4-hospital, University of Chicago-affiliated health
system located in the northern suburbs of Chicago (Wright et al., 2013). The sample was taken
from 931 beds which included adult intensive care, and neonatal intensive care, however the
sample only took patients from adult units who had central lines. Wright (2013), explains that
the design of the study is a multiphase, prospective, quasi-experimental, baseline-interventionbaseline study (Wright et al., 34). The study was split into 3 phases with phase 1 as baseline,
phase 2 as implementation of the caps, and phase 3 the removal of the caps and return to
baseline. The data represented was nominal and represented in the table as an interval.
The results of the study showed that there was significant decline in infection rate during
phase 2 with a near total comeback to baseline during phase 3 as in phase 1. There was a 1month gap between Phase 1 and 2 which allowed for time between phases and coincides with the
information earlier that it takes around 12 days post-insertion for infection to occur (Guerin,
Wagner, Rains, & Bessesen, 2010). The results were somewhat clear but required a lot of rereading in order to grasp the true results. Results were best represented through the table, and
showed the only hospital to reach phase 3 was hospital A in which the process of scrubbing the
hub became the standard and contamination increased to 12% in comparison to 5.5% during the
alcohol cap phase (Wright et al., 2013). These results seem valid but there are some threats to
validity that may alter the interpretation of the results. Only one of the four hospitals made it to
phase 3, which would make one consider it an incomplete study. The results support suggestion
for trial in other hospitals, but would require more research before making a complete change in
standard of practice.

Running Head: REDUCING THE INCIDENCE OF CENTRAL LINE INFECTIONS

Article 2
The original study Central Venous Catheter Protective Connector Caps Reduce Intraluminal
Catheter-Related Infection was published in the peer reviewed journal Association for Vascular
Access and was conducted by researchers Ramirez, Lee, and Welch, with backgrounds in
respiratory therapy, nursing, and medicine respectively. The literature background of this study
consisted of few recent reports on trials, and low level guidelines which supports the need for
this research.
Ramirez, Lee, and Welch (2012), attributed contamination of central lines to poor hand
washing before manipulation, inability to properly disinfect the connection site due to poor
design, aseptic device management, and frequency of the connector exchange (Ramirez, Lee, &
Welch, 211). Banner Estrella Medical Center, the facility this study was performed at, looked at
infections associated with intraluminal contamination in their central lines (Ramirez, Lee, &
Welch, 2012). Ramirez, Lee, and Welch (2012), found that studies of current IV practices
demonstrated that 56% of registered nurses typically do not believe it is necessary to disinfect
catheter hubs, and >90% of nurses do not cover an intermittent IV infusion (Ramirez, Lee, &
Welch, 211). Current practice at this facility was scrub the hub for 15 seconds, and
collaboration determined the use of a Curos brand cap with 70% isopropyl alcohol was
appropriate to use for their intervention.
Banner Estrella Medical Center, implemented a nonrandomized prospective trial
occurring between March 1, 2011 through February 29, 2012 in which the study looks at a 214bed community hospital that offers a variety of services and inserts >1,500 central lines annually
(Ramirez, Lee, & Welch, 2012). According to AACN standards this study falls at level B on the
evidence leveling system (Armola et al., 2009). This study uses an unpaired t test that compares

Running Head: REDUCING THE INCIDENCE OF CENTRAL LINE INFECTIONS

the incidence of CLABSI after a year period of implementing 70% isopropyl alcohol
impregnated caps at the access ports when not in use compared to their prior method of
scrubbing the hub from the past 3 years (Ramirez, Lee, & Welch, 2012). Ramirez, Lee, and
Welch (2012), clarified that they would not be doing a randomized study because the caps were
the only change made and during the study period the patient mix would be comparable with
the patient mix seen during the 3 previous years (Ramirez, Lee, & Welch, 211).
The caps were made readily available to the staff and compliance was measured routinely
through the study via observers that would round rooms and document the use of caps at the start
of every shift (Ramirez, Lee, & Welch, 2012). The barriers identified was the availability of the
caps at the bedside, which was easily rectified by implementing strips of caps that could be hung
from the IV pole. Compliance then jumped from 63% to 80% after that change (Ramirez, Lee,
& Welch, 2012). During the year that this study was implemented there was only 1 CLABSI that
occurred with the average central line days being 180 in 2011 compared to 176 in 2010. The 1
CLABSI occurred during the same month that was identified as the month with the lowest cap
compliance (Ramirez, Lee, & Welch, 2012).
The results of this study support the positive effect alcohol impregnated caps have on
reducing the incidence of CLABSIs but also highlight the need for availability of the caps in
order for them to be used by nurses. These results coincide with other studies with emphasis on
effectiveness, but this is one of the few studies that look at how the availability of the caps effect
nursing compliance. With consideration of these results, they support a change in practice from
the original scrub the hub to the use of alcohol impregnated caps.

Running Head: REDUCING THE INCIDENCE OF CENTRAL LINE INFECTIONS

Article 3
The peer reviewed journal of Infection Control and Hospital Epidemiology released the
article Disinfection of Needleless Catheter Connectors and Access Ports With Alcohol May Not
Prevent Microbial Entry: The Promise of a Novel Antiseptic-Barrier Cap written by authors
Steve Menyhay, RN, BSN and Dennis Maki, MD looking at the promise of an alcohol
impregnated cap in place of the current practice of using an alcohol swab before accessing ports.
According to AACN standards and their evidence-leveling system this article would fall under
low level D (Armola et al., 2009). The background literature cited was from early 90s and
2000s which supports the need for more current research. Menyhay and Maki (2006),
acknowledge that there is no national standard that defines the best and recommended form of
antiseptic preparation for prevention of microbial entry when the needless connector or injection
port is accessed (Menyhay & Maki, 24). The purpose of this study is to see which method of
antiseptic cleansing before access renders the least amount of contamination. They consider that
the simple scrubbing with a pad on the outside of the surface does not effectively clean the
potential contamination within the port which is what the leur lock threading of the antiseptic
barrier cap can better reach (Menyhay & Maki, 2006).
The design of this study is a prospective simulation therefore the population includes 36
connectors from 3 different manufacturers with one device from each as a negative control
(accessed without precontamination). And the remaining 35 devices were contaminated by
immersing the membranous surface into a suspension of Enterococcus faecalis (Menyhay &
Maki, 2006). Menyhay and Maki (2006) used 10 of the contaminated protectors as devices that
were to be cleansed for 3-5 seconds with an alcohol swab, 20 contaminated connectors of each

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Running Head: REDUCING THE INCIDENCE OF CENTRAL LINE INFECTIONS

manufacturer had the antiseptic cap, and 5 were contaminated with no cleansing before access
(Menyhay & Maki, 25).
The results show that transmission of E. faecalis was significantly less with the use of the
antiseptic barrier cap than in any of the other two trials with only 1 transmission of the 60
(Menyhey & Maki, 2006). The results were also shown in the form of a table which made data
interpretation even easier. There was not any specific statistical analysis mentioned, however the
data and results were represented nominally and were appropriate. The results answered the
question of which form of cleansing rendered the least amount of transmission of E. faecalis,
however the data did not break down if one manufacturer had better results than another, the only
thing mentioned within the study by Menyhey and Maki (2006), was The results were very
similar for connectors from each 3 manufacturers (data not shown) (Menyhey & Maki, 25).
The results would be appropriate to bring to a nursing floor, however a nurse would have better
reception if they brought forward clinical studies that support the data. The sample size of this
study is small with only 36 connectors tested, and it was under unrealistic situations since these
connectors were not actually connected to a human and did not take into consideration the length
these catheters usually stay within an individual, not the 24 hour time frame they were tested in.
The Significance to Nursing
The knowledge, skills, and attitude (KSA) requirements outlined by the quality and safety
education for nurses (QSEN) define six requirements all nurses must meet in order to be
effective. The six KSAs include, patient-centered care, teamwork and collaboration, evidencebased practice (EBP), quality improvement (QI), safety, and informatics (QSEN, 2014). The
data collected from the research articles meet this criteria in the following ways.

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Running Head: REDUCING THE INCIDENCE OF CENTRAL LINE INFECTIONS

The study conducted by Ramirez, Lee, and Welch (2012), represents team work and
collaboration well because the authors have backgrounds in respiratory, nursing, and physician
practice respectively. It is great to see three different professions seek out an answer that best
represents quality improvement, and patient safety and care. Each article supports the use of
alcohol impregnated caps on access ports, and thus improving patient quality and the research
nurses conduct represents evidence-based practice in nursing care. The article written by Guerin,
Wagner, Rains, and Bessesen (2010), looks at the post insertion timeline and determined that
after insertion is where infection occurs and with staff collaboration, education on proper
cleaning, and utilization of proper cleansing technique before manipulation will reduce the
incidence of infection (Guerin, Wagner, Rains, & Bessesen, 432). This study encompasses all
aspects of KSAs and acts as a springboard into more recent articles, such as the article by
Wright, et al. (2013) Continuous Passive Disinfection of Catheter Hubs Prevents Contamination
and Bloodstream Infection, which look at the comparison between the alcohol swabs, and the
alcohol impregnated pads (Wright et al., 2013) which supports how nursing research is
constantly looking for ways to improve patient safety. Utilizing and conducting research meets
the desire for more knowledge by nurses, improving skills, and having the right attitude about
patient quality and care which answers each aspect of KSAs (QSEN, 2014).
The three article critiques support the use of alcohol impregnated caps, however none of the
evidence reached higher than level B by AACN standards (Armola et al., 2009). Collectively
there have been many smaller studies that have been done that substantially support the use of
alcohol impregnated caps, with some resulting in a change in protocol within their facility. This
information would be appropriate to bring to a local board for quality and safety, and implement
into a facility.

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Running Head: REDUCING THE INCIDENCE OF CENTRAL LINE INFECTIONS

References
Armola, R.R., Bourgault, A.M., Halm, M.A., Board, R.M., Bucher, L., Harrington, L.,
Medina, J. (2009). AACN Levels of Evidence: Whats New? Critical Care Nurse,29, 7073. Retrieved from http://www.mc.vanderbilt.edu
Central Line-Associated Bloodstream Infection (CLABSI) Event. (2014). . Retrieved from
http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf
Charron, K. K. (2012). Decreasing Central Line Infections and Needlestick Injury Rates:
Combining Best Practice and Introducing a Luer-Activated Intravenous Therapy System
and Antimicrobial Intravenous Connector. Journal Of Infusion Nursing, 35(6), 370-375.
doi:10.1097/NAN.0b013e3182706ab8
Guerin, K., Wagner, J., Rains, K., & Bessesen, M. (2010). Reduction in central line-associated
bloodstream infections by implementation of a postinsertion care bundle. American
Journal Of Infection Control,38(6), 430-433. doi:10.1016/j.ajic.2010.03.007
Menyhay, S., & Maki, D. (2006). Disinfection of needleless catheter connectors and access ports
with alcohol may not prevent microbial entry: the promise of a novel antiseptic-barrier
cap. Infection Control & Hospital Epidemiology, 27(1), 23-27.
QSEN Institute (2014). Pre-licensure KSAs. Retrieved from http://qsen.org/competencies/prelicensure-ksas/#patient-centered_care
Ramirez, C., Lee, A. M., & Welch, K. (2012). Central Venous Catheter Protective Connector
Caps Reduce Intraluminal Catheter-Related Infection. Journal Of The Association For
Vascular Access, 17(4), 210-213. doi:10.1016/j.java.2012.10.002

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Running Head: REDUCING THE INCIDENCE OF CENTRAL LINE INFECTIONS

Wright, M., Tropp, J., Schora, D., Dillon-Grant, M., Peterson, K., Boehm, S., et al. (2013).
Continuous passive disinfection of catheter hubs prevents contamination and bloodstream
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