Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

An Integrative Review: Central Line Interventions

Jacqueline Andriano
Bon Secours Memorial College of Nursing
Nursing Research
NUR 4122
5/1/16
I pledge

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

Abstract
The goal of this integrative review is to evaluate the literature related to central line-associated
bloodstream infections (CLABSIs) and interventions that aim to decrease the rate of CLABSIs.
The number of CLABSIs in the United States and abroad is shocking. There are several
interventions that can be implemented that have been found to significantly decrease the rate of
CLABSIs, but the most effective intervention has not yet been identified. The research design is
an integrative review. The search for research articles was conducted using the search engine
EBSCO. The search yielded 1,504 articles. Five of these articles met inclusion criteria. The
results and findings analysis of the five articles suggested the implementation of a disinfectant
cap that contains 3.15% chlorhexine gluconate-70% isopropyl alcohol and education on proper
use of this intervention. Limitations of the integrative review include: the researcher being a full
time nursing student, having assignments in other classes, limited databases to conduct the
review, and a five article limit for the assignment. Future research should include the
implementation of a disinfectant cap that contains 3.15% chlorhexidine gluconate-70% isopropyl
alcohol and the evaluation of different strategies for teaching about CLABSIs and central line
maintenance.

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

An Integrative Review: Central Line Interventions

The purpose of this study is to provide an integrative review related to central line
interventions and their effects on central line-associated bloodstream infections (CLABSIs). The
number of CLABSIs that occur in the United States and abroad is shocking (Merrill, Sumner,
Linford, Taylor, & Macintosh, 2014). It is estimated that 200,000-400,000 episodes of
bloodstream infections occur annually in U.S. hospitals, resulting in increased length of stay,
cost, and patient morbidity and mortality (Merrill et al., 2014, p. 1274). One issue that needs to
be resolved regarding central lines is the variability in policies and clinical practice around the
maintenance of central lines (Hong, Morrow, Sandora, & Priebe, 2013). This area interests the
researcher due to the vast number of CLABSIs that occur each year, and the impact they have on
patients. Therefore, the proposed PICOT question is as follows: In hospitalized patients, which
intervention decreases the number of CLABSIs more, disinfectant caps or disinfecting the
needleless connector (NC) with alcohol before accessing the port?
Research Design, Search Methods, & Search Outcomes
The research design is an integrative review. The search for research articles was
conducted using the database EBSCO. The search terms included, chlorhexidine in combination
with alcohol, needleless connectors, disinfectant caps with alcohol and chlorhexidine,
disinfectant caps, passive, CLABSI, education, and qualitative. The search yielded 1,504
articles. The articles were narrowed down to peer-reviewed qualitative and quantitative journal
articles, published in English, and written between 2011-2016. The articles had to relate to the
researchers PICOT question, In hospitalized patients, which intervention decreases the number
of CLABSIs more, disinfectant caps or disinfecting the needleless connector with alcohol before
accessing the port? The articles were then selected based on the following inclusion criteria:

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

hospitalized patients, central line-associated bloodstream infection, disinfectant cap, and alcohol.
The articles were then reviewed based on inclusion criteria and whether or not the research was
valuable in answering the PICOT question. Research articles that did not meet criteria were not
included. This sampling method produced five articles related to decreasing CLABSIs, including
four quantitative and one qualitative.
Findings/Results
The findings and results of the five reviewed studies indicate several interventions that
have a significant impact on CLABSI rates (DeVries, Manco, and Valentine (2014); Dumyati et
al., 2014; Hong et al., 2013; McAlearney, Hefner, Robbins, Harrison, and Garman (2015);
Merrill et al., 2014). A summary of the research articles is presented in Appendix 1. The
researcher structured the review according to the following categories: disinfectant cap,
chlorhexidine gluconate-isopropyl alcohol, education intervention, and organizational factors.
Disinfectant Cap
The studies conducted by (DeVries et al. 2014) and (Merrill et al. 2014) both looked at
the impact of disinfectant caps on CLABSIs. In the quantitative study conducted by DeVries et
al. (2014), the researchers aimed to discover an approach for disinfecting connectors that would
address the issues of noncompliance and variation from proper technique. This experiment used
a quasi-experimental design. The sample consisted of the patients on three intensive care units
that had either a central line or a peripheral line in Methodist Hospital in Chicago, Illinois. The
major variables studied were the disinfectant cap and bloodstream infections (BSIs). The
hospitals implemented use of the disinfectant cap (SwabCap, Excelsior Medical, Neptune, NJ)
on these units for three months (DeVries et al., 2014). The authors did not discuss how the data
were analyzed. After the SwabCap was implemented, the bloodstream infection rate dropped

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

49.3% from the preintervention rate, and this result was statistically significant (DeVries at al.,
2014). This study contributes to the body of literature because it shows that one way to fix the
problem of healthcare providers not complying with proper disinfecting techniques is a
disinfectant cap.
In the quantitative study conducted by Merrill et al. (2014), the authors analyzed the
effect of the implementation of universal IV needleless connector disinfectant caps on the rate
and type of CLABSI and estimated costs using a standard central line bundle. The study design
used a quasi-experimental design. The sample consisted of 430 beds on a tertiary care trauma
one center in the United States Mountain West. A luer-lock disinfectant cap with 70% alcohol
was implemented in all patients (newborn to adults) with peripheral and central lines residing on
13 inpatient units at 1 hospital (Merrill et al., 2014, p. 1275). The major variables studied
include: intravenous (IV) needleless connector disinfectant caps (Curos Disinfecting Port
Protector, Curos, San Diego, CA; a plastic-threaded device that contains 70% isopropyl alcohol),
CLABSI rates, costs of CLABSIs, and disinfectant cap compliance (Merrill et al., 2014). Audits
were conducted one to two times per week, which is how compliance was determined.
The researchers used IBM SPSS version 22.0 to analyze the data. A generalized linear
model using a Poisson distribution was fit to determine if there was a significant difference in
CLABSI rates following implementation of the disinfectant cap (Merrill et al., 2014, p. 1276).
The results showed that CLABSI rates decreased with the implementation of a disinfectant cap,
and these results were statistically significant. This study is significant because it emphasizes that
disinfectant caps are one way to decrease CLABSI rates.
Chlorhexidine Gluconate-Isopropyl Alcohol

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

In the quantitative study conducted by Hong et al. (2013), it was discussed that there is
variability in policies and clinical practice around disinfection of NCs, including scrub duration
and the disinfection itself (Hong et al., 2013, p. 77). The researchers compared needleless
connectors (NC) disinfection with 3.15% chlorhexidine gluconate-70% isopropyl alcohol versus
70% isopropyl alcohol using different scrub time durations. The study also evaluated whether or
not chlorhexidine-containing products have residual antimicrobial activity on NCs. The study
used a quasi-experimental design. The sample was not specifically discussed. This experiment
was conducted in a laboratory. The major variables studied include: Enteroccocus faecalis,
Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermis, Candida albicans,
contamination level, 3.15% chlorhexidine gluconate-70% isopropyl alcohol, 70% isopropyl
alcohol, scrub durations (15 and 30 seconds), and residual disinfection activity of 3.15 %
chlorhexidine gluconate-70% isopropyl alcohol.
The study consisted of contaminating NCs with different microbes, disinfecting the NCs
with either the 3.15% chlorhexidine gluconate-70% isopropyl alcohol combination or 70%
isopropyl alone, and then quantifying the contamination level after implementing the
intervention. The contamination level was quantified both by counting colony-forming units
(CFU) in the flushed media on agar (plated immediately, a less sensitive measure of
contamination) and by measuring the OD650 after overnight growth, with contamination defined
as OD650 > 0.1 (Hong et al., 2013, p. 78). The Fisher exact test was used to compare the
percent contamination for different disinfectants at the same scrub time (Hong et al., 2013).
CFU/milliliter in flushed media were compared using Kruskal-Wallis analysis of variance with
Dunns multiple comparison test (Hong et al., 2013, p. 78). The researchers found that
chlorhexidine-alcohol is more effective than alcohol alone. For NCs contaminated by S aureus

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

and P aeruginosa, a swipe (<1 second scrub) with alcohol was significantly less effective than
with chlorhexidine-alcohol (Hong et al., 2013, p. 78). They also discovered that chlorhexidinealcohol has residual antimicrobial activity on NCs up to 24 hours after application (Hong et al.,
2013). This study contributes to the body of literature by emphasizing the benefits of using
chlorhexidine and alcohol instead of alcohol alone to disinfect NCs.
Education Intervention
The experimental study by Dumyati et al. (2014) examined the implementation of an
intervention that focused on engagement of nursing staff and leadership, nursing education on
central line care maintenance, competence evaluation, audits of line care, and regular feedback
on CLABSI rates. Although central lines are used frequently outside of the intensive care unit
(ICU), there is not a lot of research that has been conducted on prevention of CLABSIs on other
units (Dumyati et al., 2014). The study used a quantitative study, and the design was quasiexperimental. The sample consisted of 6 hospitals in the Rochester region. The hospitals
selected non-ICU units in which central venous catheters (CVCs) were regularly used to
participate in the project, for a total of 37 adult units (Dumyati et al., 2014, p. 724). The major
variables studied include: education intervention, engagement of nursing staff and leadership,
CLABSI rates, central venous catheter (CVC) maintenance bundle.
The intervention consisted of three parts which include: expansion of the collaborative
team, education, and process measures. First, the researchers increased collaborative team
membership by including nursing educators, nursing leadership, hospital quality and safety staff,
vascular access team (VAT) staff, and 1 hospitalist physician champion (Dumyati et al., 2014).
The educational part of the intervention was a computer-based education module. This module

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

was mandated by each hospital, and the completion of this course was tracked electronically.
Lastly, compliance was assessed by auditing the care and maintenance of central lines.
Two data collection tools were created with input from all stakeholders: a nursing
practice audit tool, consisting of observation of CVC dressing changes and access of needleless
connectors, and a dressing integrity audit tool, consisting of documentation of CVC dressing
status and dates of dressing, tubing, and needleless connector changes (Dumyati et al., 2014, p.
725). CLABSI rates were divided into three categories (specialty care units, ICU step-down, and
medical surgical). Interrupted time series analysis was performed in SAS version 9.2 (SAS
Institute, Cary, NC) using PROC ARIMA to estimate the intervention effect while accounting for
potential underlying time trends in the data (Dumyati et al., 2014, p. 727). The researchers also
used a Poisson regression to compare CLABSI rates across the three study phases by computer
rate ratios (RRs) and 95% confidence intervals (Dumyati et al., 2014). The results showed a
statistically significant decrease of CLABSI rates after the intervention. This study is valuable to
the body of literature because it highlights the importance of educating the nursing staff about
proper CVC care and the prevalence of CLABSIs.
Organizational Factors
Prior research showed a significant decrease in CLABSI rates with the implementation of
a bundle along with line insertion and maintenance teams in all of the hospitals (McAlearney, et
al., 2015). However, only some of the hospitals were able to sustain this decrease. McAlearney et
al. (2015) suggested that organizational factors could be the reason for this difference. There was
not any research that examined the impact of organizational factors on CLABSI rates, so the
researchers constructed a study to fill this gap.

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

This was a phenomenological study that focused on perceptions of organizational factors

regarding CLABSI. The sample consisted of five higher-performing hospitals and three lowerperforming hospitals (demonstrated less consistent results-for example, variation between units
or occasional sharp increases in their infection rate trends) (McAlearney et al., 2015). The major
variables studied include: higher-performing hospitals, lower-performing hospitals, key
organizational characteristics (i.e., size, number, and size of ICUs, teaching status, and
geography) (McAlearney et al., 2015). Interviews were conducted over two day visits by three
research team members. A total of 194 in-person interviews were conducted lasting 30-60
minutes each. Interviewees included administrative leaders, clinical leaders, professional staff,
and frontline physicians and nurses (McAlearney et al., 2015, p. 558). There were two versions
of the interview (clinical and non-clinical), and both consisted of a semi-structured interview
guide.
The researchers used a constant comparative analytic approach to analyze the 1,236
pages of interview transcripts. The authors classified the data into categories. Atlas. Ti, version
6.0. qualitative data analysis software was used to support the analysis (McAlearney et al.,
2015). The researchers discovered that higher-performing hospitals have the goal of obtaining
and sustaining zero CLABSI rates, a strong alignment and collaboration between nurse leaders
and physicians, include CLABSI prevention topics as part of physician orientation and resident
education, systemically assess and address unit-level educational needs, and have their nurse
managers share the CLABSI rates and trends on their units in multiple places on the unit
(McAlearney et al., 2015). The researchers believe that these factors contribute to the higherperforming hospitals ability to obtain and sustain zero CLABSI rates. This study is beneficial to

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

10

the body of literature because it brings to light the impact that organizational factors have on
decreasing CLABSI rates.
Discussion and Implications
The findings of the integrative review suggest several interventions have been shown to
decrease CLABSI rates. Therefore, the review findings relate to and support the researchers
PICOT question: In hospitalized patients, which intervention decreases CLABSI rates more,
disinfectant caps or disinfecting the needleless connector with alcohol before accessing the port?
DeVries et al. (2014) and Merrill et al. (2014) both discovered a decrease in CLABSIs with the
implementation of a disinfectant cap. Education on central line maintenance and CLABSI trends
was also found to decrease CLABSI rates (Dumyati et al., 2014, McAlearney et al., 2015).
Certain organizational factors were found to have an impact on a hospitals ability to obtain and
sustain zero CLABSIs (McAlearney et al., 2015). Hong et al. (2013) discovered that 3.15%
chlorhexidine gluconate-70% isopropyl alcohol decreases the amount of microbes on needleless
connectors more than 70% isopropyl alcohol alone, and 3.15% chlorhexidine gluconate-70%
isopropyl alcohol has residual antimicrobial activity on NCs.
The implications of the findings suggest that implementation of a disinfectant cap that
contains 3.15% chlorhexidine gluconate-70% isopropyl alcohol and education on proper use of
this cap along with CLABSI trends should significantly reduce the number of CLABSIs. Future
research should be conducted on a disinfectant cap that contains 3.15% chlorhexidine gluconate70% isopropyl alcohol. Different education strategies should also be examined.
Limitations
The researcher acknowledges that there are several limitations that have influenced this
integrative review. One limitation is that the review was conducted over a rather short time span

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

11

of only three months. The researcher is a full time nursing student and has two jobs, working
anywhere from six to twenty hours a week. Therefore, the researcher had limited time available
to work on this review due to other assignments and commitments. This was the researchers
first attempt at writing an integrative review. The assignment was limited to five articles, which
were found solely from the databases available at the researchers school.
Conclusion
The findings of this integrative review support the researchers PICOT question: In
hospitalized patients, which intervention decreases CLABSIs more, disinfectant caps or
disinfecting the needleless connector before accessing the port? DeVries et al. (2014) and Merrill
et al. (2014) found that the implementation of disinfectant caps decrease CLABSIs more. It was
also found that 3.15% chlorhexidine gluconate-70% isopropyl alcohol is more effective in
decreasing contamination of central lines than alcohol alone (Hong et al., 2013). The effects of
disinfectant caps that contain 3.15% chlorhexidine gluconate-70% isopropyl alcohol on
CLABSIs still needs to be evaluated.
The findings of this integrative review are beneficial because the number of CLABSIs in
the United States and abroad is shocking (Merrill et al., 2014), and this review brings light to
what interventions can be implemented to address this problem. As a result of this integrative
review, healthcare providers will know what interventions have been proven to decrease
CLABSI rates the most. This review also addresses other factors, such as organizational factors,
that are significant to implement if a hospital desires to obtain and maintain zero CLABSIs.

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

12

References
DeVries, M., Mancos, P.S., Valentine, M.J. (2014). Reducing bloodstream infection risk in
central and peripheral intravenous lines: Initial data on passive intravenous connector
disinfection. Journal of the Association for Vascular Access, 19(2), 87-93.
Dumyati, G. Concannon, C., Wijngaarden, E.V., Love, T.M. Graman, P., Pettis, A.M., Greene, L.,
El-Daher, N., Farnsworth, D., Quinlan, G., Karr, G., War, L., Knab, R., & Shelly, M.
(2014). Sustained reduction of central line-associated bloodstream infections outside the
intensive care unit with a multimodal intervention focusing on central line maintenance.
American Journal of Infection Control, 42, 723-30.
Hong, H., Morrow, D.F., Sandora, T.J., & Priebe, G.P. (2013). Disinfection of needleless
connectors with chlorhexidine-alcohol provides long-lasting residual disinfectant activity.
American Journal of Infection Control, 41, 77-79.
McAlearney, A.S., Hefner, J.L., Robbins, J., Harrison, M.I., & Garman, A. (2015). Preventing
central line-associated bloodstream infections: A qualitative study of management
practices. Infection Control & Hospital Epidemiology, 36(5), 557-563.
Merrill, K.C., Sumner, S., Linford, L., Taylor, C., & Macintosh, C. (2014). Impact of universal
disinfectant cap implementation on central line-associated bloodstream infections.
American Journal of Infection Control, 42, 1274-1277.

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

Nursing Research
Appendix 1: Summary of the Literature
(Central Line Interventions)
First Author
(Year)/Qualifications

Background/Problem
Statement

DeVries et al. (2014). Michelle DeVries has a Masters of Public

Health degree, and she has published previous research. Patricia
Mancos has published previous research on central lineassociated bloodstream infections (CLABSIs). Mary Valentine
has a Masters of Science in Nursing degree. These authors are
qualified to conduct research on CLABSIs because one of the
researchers has had prior experience conducting research
specifically on CLABSIs.
The authors did a good job of giving background information
about CLABSIs. The problem statement was that nurses are not
following proper manual disinfection of the hubs of intravenous
(IV) needleless connectors. There is a problem with
noncompliance and variation of proper technique.
The purpose of this research was to discover an approach to
disinfecting connector hubs that would overcome the problem
with variation in scrubbing technique (DeVries, Mancos, &
Valentine, 2014).

Conceptual/theoretica
l Framework
Design/
Method/Philosophical
Underpinnings

There was no mention of a conceptual/theoretical framework.

Sample/
Setting/Ethical
Considerations

The sampling method was not discussed. Methodist Hospitals is

a not-for-profit, community-based health care system with 2 fullservice acute care facilities located 1 hour east of Chicago,
Illinois (DeVries et al., 2014, p. 88). The nurses at Methodist
Hospitals chose the device technology that they wanted to use to

Quantitative
Quasi-experimental
No philosophical underpinnings were mentioned.

13

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

address the issues with connector hub disinfection (DeVries at al.,
2014). After its selection by bedside nurses, the disinfection cap
was used in each of Methodists 3 intensive care units for a 3month span (DeVries et al., 2014, p. 89). No BSIs occurred
during this period (DeVries et al., 2014, p. 89). Because of this
record of successful use, the hospital implemented use the
disinfection cap throughout the hospital system for application on
central/PICC and peripheral lines, including tubing and Y-sites
(DeVries at al., 2014, p. 89). The researchers did not mention
how many patients were included in the sample.

Measurement
Tool/Data Collection
Method

The researchers did not discuss informed consent. All that was
mentioned was that the data reported did not require formal
approval by the institutional review board (DeVries et al., 2014).
Disinfection Cap- a disinfection cap (SwabCap,
Excelsior Medical, Neptune, NJ) that passively disinfects
the hub with IPA (isopropyl alcohol) (DeVries et al.,
2014, p. 88).
PIVs
BSI rates-blood stream infections
There was no mention of how data was collected. The authors
mentioned that an ongoing prospective observational study was
conducted on the caps use (DeVries et al., 2014).

Data Analysis

The authors did not discuss how the data was analyzed.

Findings/Discussion

After SwabCap use was implemented, the BSI rate dropped

49.3% from the preintervention rate of about 0.075/100 patient
days (DeVries et al., 2014, p. 89). The postintervention rate is
roughly 0.038/100 patient days (DeVries at al., 2014, p. 89).
This result is statistically significant (P < .00037) (DeVries at
al., 2014, p. 89).

Major Variables
Studied (and their
definition), if
appropriate

Although implementation of a disinfectant cap has shown to

decrease the amount of CLABSIs, this study does not prove that
a disinfectant cap is the best way to decrease CLABSI rates.
However, the disinfectant cap does eliminate many of the issues
with manually disinfecting the hub.
Appraisal/Worth to
practice

The researchers left out many important parts of a research

article. The discussion of their sample was very weak. This study

14

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

was not approved by the Institutional Review Board, and the
authors did not discuss informed consent. There were several
limitations to this study, such as the small size of the hospitals,
the sample only including a few hospitals from the same
healthcare system, and the main reason for CLABSIs in this
hospital could be that the nurses did not follow proper techniques
for manually disinfection of the hub. The researchers also did not
mention how data was collected.
Although the results of this study do not prove that disinfectant
caps will definitely decrease CLABSI rates in all hospitals, they
do show that disinfectant caps should be considered in hospitals
that have healthcare providers that do not comply with proper
manual disinfection techniques. This research is still valuable
because it brought to healthcare workers attention that there are
many issues with manually disinfecting hubs. A few issues that
could be resolved with the implementation of a disinfectant cap
include: noncompliance of proper manual disinfecting technique
and difficulty monitoring proper technique.
First Author
(Year)/Qualifications
Background/Problem
Statement

Dumyati et al. (2014). Ghinwa Dumyati has published several

studies on CLABSIs.
The researchers gave great background information about central
line-associated bloodstream infections (CLABSIs).
Central venous catheter use is common outside the intensive
care units (ICUs), but prevention in this setting is not well
studied (Dumyati, Concannon, Wijingaarden, Love, Graman,
Pettis, Greene, El-Daher, Farnsworth, Quinlan, Karr, Ward, Knab,
& Shelly, 2014, p. 723).

Conceptual/theoretica
l Framework

Design/
Method/Philosophical
Underpinnings

Implementation of the intervention was guided by a translating

evidence into practice model that focuses on strategies for
engagement, education, execution, and evaluation of the
prevention effort (Dumyati et al., 2014, p. 724).
Quantitative
Quasi-experimental
No philosophical underpinnings were discussed.

Sample/
Setting/Ethical

The sample consisted of 6 hospitals in the Rochester region

(Dumyati et al., 2014). Participating hospitals included 1 tertiary

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Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

Considerations

Major Variables
Studied (and their
definition), if
appropriate

Measurement
Tool/Data Collection
Method

care hospital, 3 community hospitals with a medical teaching

program, and 2 rural hospitals ranging in size from 61 to 739
beds (Dumyati et al., 2014, p. 724). The hospitals selected nonICU units in which CVCs were regularly used to participate in
the project, for a total of 37 adult units (Dumyati et al., 2014, p.
724).
This research was approved by the Institutional Review Board of
each hospital. The researchers did not discuss informed consent
or how confidentiality was maintained.
Education intervention-taught appropriate
disinfection of needleless connectors and
standardization of this process across
hospitals; policies focusing on hand hygiene,
catheter site care and routine dressing
changes, replacement of administration sets,
and drawing blood for cultures from CVC
(Dumyati et al., 2014)
Engagement of nursing staff and
leadership
CLABSI rates- (number of cases divided by
number of line-days) (Dumyati et al., 2014,
p. 727).
Central venous catheter (CVC)
maintenance bundle- 5 evidence based
components: hand hygiene; aseptic technique
during use of needleless connectors; CVC
dressing changes; frequency of needleless
connector, IV line, and dressing changes; and
regular assessment of the need of the CVC
(Dumyati et al., 2014, p. 724).
Staphylococcus
Two data collection tools were created with input from all
stakeholders: a nursing practice audit tool, consisting of
observation of CVC dressing changes and access of needleless
connectors, and a dressing integrity audit tool, consisting of
documentation of CVC dressing status and dates of dressing,
tubing, and needleless connector changes (Dumyati et al., 2014,
p. 725). Nursing staff and IPs performed 800 assessments of
dressing integrity and 250 direct face-to-face nursing practice
observations across the participating hospitals over the 12-month

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Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

intervention period (Dumyati et al., 2014, p. 725).

Data Analysis

Findings/Discussion

Infection preventionists (IPs)

Rates were stratified by unit type into 3 categories: specialty
care units (eg, bone marrow transplant, oncology), ICU stepdown, and combined medical, surgical, and mixed medicalsurgical (Dumyati et al., 2014, p. 727). Interrupted time series
analysis was performed in SAS version 9.2 (SAS Institute,
Cary,NC) using PROC ARIMA to estimate the intervention effect
while accounting for potential underlying time trends in the data
(Dumyati et al., 2014, p. 727). In addition, to characterize the
infection profiles across units and hospitals, we compared
CLABSI rates across the 3 study phases by computing rate ratios
(RRs) and 95% confidence intervals (CIs) using Poisson
regression (Dumyati et al., 2014, p. 727).
During the baseline period (phase 1), the overall CLABSI rate
was 2.6/1000 line-days (95% CI, 2.2-3.0) (Dumyati et al., 2014,
p. 727). The rate declined during and after the intervention, as
demonstrated by time series analysis (Dumyati et al., 2014, p.
727). The overall rate dropped to 1.3/1000 line-days at postintervention (phase 3), a statistically significant reduction of 50%
from baseline (p= .0179) (Dumtayi et al., 2014, p.727).
The implementation of an education intervention on appropriate
disinfection of needleless connectors and the implementation of a
CVC maintenance bundle significantly decreased the CLABSI
rates on non-ICU units.

Two factors contributed to our observed reduction in CLABSI

rates: (1) provision of education to improve nurses knowledge
and performance of CVC care, particularly increased knowledge
of and compliance with scrubbing needless connectors, and (2)
engagement of nursing staff and increased awareness of the
burden of CLABSIs through feedback of CLABSI rates and a
multidisciplinary review of each affected patient, making the
infection more relevant to clinical staff (Dumyati et al., 2014, p.
728)
Appraisal/Worth to
practice

The articles methods section was a little confusing. The

researchers did not mention whether or not informed consent was
obtained. This study does have several strengths such as there

17

Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

was a large sample and it was conducted over four and a half
years. This article is very helpful is answering the PICOT
question of which intervention decreases CLABSI rates more
disinfectant caps or alcohol swabs because this research shows
that another important part of decreasing CLABSI rates is
educating healthcare providers on proper techniques. This article
is valuable because it filled the gap in the literature of prevention
of CLABSIs in non-ICU settings.
First Author
(Year)/Qualifications

Background/Problem
Statement

Hong et al. (2013). Haeyeon Hong and Debra Forbes Morrow

have published research. Thomas J. Sandora and Gregory P.
Priebe have published research on central line-associated
bloodstream infections (CLABSIs), and they both have a
Doctor of Medicine degree (MD). These authors are qualified
to conduct research on CLABSIs due to their previous
experience and education.
The researchers did a great job of giving background
information about CLABSIs and discussing the current
research.
The problem discussed in the article is that there is variability
in policies and clinical practice around disinfection of NCs,
including scrub duration and the disinfection itself (Hong,
Morrow, Sandora, & Priebe, 2013, p. 2013).
The purpose of this article: We undertook this laboratory study
to compare NC disinfection with 3.15% chlorhexidine
gluconate-70% isopropyl alcohol versus 70% isopropyl alcohol
using different scrub durations (Hong et al., 2013, p.77). We
also assessed whether a chlorhexidine-containing product
would have residual antimicrobial activity on NCs (Hong et
al., 2013, p. 77).

Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings

The researchers model of needleless connector (NC)

contamination and sample sizes were based on prior work
conducted by Menyhay and Maki (Hong et al., 2013).
Quantitative
Quasi-experimental
No philosophical underpinnings were mentioned.

Sample/ Setting/Ethical
Considerations

The sample was not specifically discussed. The sampling

method and sample size was determined by prior work

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Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

Major Variables Studied

(and their definition), if
appropriate

Measurement Tool/Data
Collection Method

Data Analysis

Findings/Discussion

conducted by Menyhay and Maki. The study was conducted in

a laboratory. Ethical considerations were not discussed.
Enterococcus faecalis (strain 12030)
Pseudomonas aeruginosa (strain PA01)
Staphylococcus aureus (strain Newman)
Staphylococcus epidermidis (strain M187)
Candida albicans (strain SC5314)
OD650
The contamination level was quantified both by counting
colony-forming units (CFU) in the flushed media on agar
(plated immediately, a less sensitive measure of contamination)
and by measuring the OD650 after overnight growth, with
contamination defined as OD650 >0.1 (Hong et al., 2013,
p.78).
The percent contamination for different disinfectants at the
same scrub time was compared using Fisher exact test (Hong
et al., 2013, p.78). CFU/milliliter in flushed media were
compared using Kruskal-Wallis analysis of variance with
Dunns multiple comparison test (Hong et al., 2013, p.78).
For 15- or 30-second scrub with chlorhexidinealcohol, none of the NCs showed contamination
(all OD650 <0.1) for all 5 microbes (Hong et al.,
2013, p.78). For NCs contaminated by S aureus
and P aeruginosa, a swipe (<1 second scrub) with
alcohol was significantly less effective than with
chlorhexidine-alcohol (Hong et al., 2013, p. 78).
Chlorhexidine-alcohol is more effective than
alcohol alone. Another benefit of using
chlorhexidine-alcohol is that it has residual
disinfection activity on NCs up to 24 hours after
application (Hong et al., 2013).

Appraisal/Worth to
practice

This article is valuable in answering the PICOT question of

whether alcohol swabs or disinfectant caps decrease CLABSIs
more. It is important to note that chlorhexidine-alcohol
according to this research has the best results for decreasing
CLABSIs. It is also beneficial to note that the most effective
scrub time is still unknown. Although this research was
conducted in vitro, it is still applicable to the hospital setting.

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Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

The researchers did not discuss the exact time frame that their
experiment was conducted, so it would be difficult to repeat
this experiment. The researchers also did not discuss whether
or not the research was statistically significant.
First Author
(Year)/Qualifications

Background/Problem
Statement

McAlearney et al. (2015); The authors are all qualified to

conduct research on central line-associated blood stream
infections (CLABSIs). McAlearney, Hefner, and Garman have
all conducted prior research on CLABSIs. Jennifer Hefner,
Julia Robbins, and Michael Harrison all have PhDs. Ann
Scheck McAlearney has a ScD.
The authors did a great job at giving background information
on CLABSIs.
The problem statement was that prior research showed a
significant decrease in CLABSI rates with the implementation
of a bundle along with line insertion and maintenance teams in
all of the hospitals. However, only some of the hospitals were
able to sustain this decrease while others were not. It was
suggested that organizational factors could be the reason for
this difference. There was not any research that examined the
impact of organizational factors on CLABSI rates, so the
researchers decided to fill the gap.

Conceptual/theoretical
Framework

There was not a conceptual/theoretical framework identified.

Design/
Method/Philosophical
Underpinnings

Qualitative
Phenomenology
No philosophical underpinnings were mentioned.

Sample/ Setting/Ethical
Considerations

The sample consisted of 8 study sites ranged in size from 300bed single hospitals to 1,000-plus-bed health systems and
included community hospitals, teaching hospitals, academic
medical centers, and health systems (McAlearney, Hefner,
Robbins, Harrison, & Garman, 2015). The sample consisted of
five higher-performing and three lower-performing hospitals.
The sampling method was identified.
The ethical considerations were barely mentioned. The
researchers did not acknowledge whether or not the participants
were fully informed about the nature of research.

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Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

Major Variables Studied
(and their definition), if
appropriate

Higher performing hospitals

Lower performing hospitals-demonstrated less
consistent (defined as: variation between units or
occasional sharp upticks in their infection rate trends)
Key organizational characteristics (i.e., size, number,
and size of ICUs, teaching status, and geography)

Measurement Tool/Data
Collection Method

During 2-day visits between June 2011 and October 2012 to

each of the 8 hospitals, 3 research team members conducted a
total of 194 in-person interviews lasting 30 to 60 minutes each
(McAlearney et al., 2015, p. 558). Interviewees included
administrative leaders, clinical leaders, professional staff, and
frontline physicians and nurses. The interviews consisted of a
similar mix of key informants at each site, using 2 versions
(i.e., clinical and nonclinical) of a semi-structured interview
guide (McAlearney et al., 2015, p. 558).

Data Analysis

A constant comparative analytic approach involving both

inductive and deductive methods was used to analyze 1,236
pages of interview transcripts and determine what distinguished
higher and lower performing sites (McAlearney et al., 2015).
The data was classified into categories and then coded
(McAlearney at al., 2015). Atlas. Ti, version 6.0, qualitative
data analysis software was used to support the analysis
(McAlearney et al., 2015).

Findings/Discussion

Having the goal of obtaining and sustaining 0 CLABSI rates, a

strong alignment and collaboration between nurse leaders and
physicians, including CLABSI prevention topics as part of
physician orientation and resident education, systemically
assessing and addressing unit-level educational needs, and
having nurse managers share the CLABSI rates and trends on
their units in multiple places on the unit all lead to a decrease in
CLABSI rates. When these factors are implemented a decrease
in CLABSI rates is also able to be sustained.

Appraisal/Worth to
practice

The researchers seemed to leave out very important

components of a research study, such as ethical considerations,
theoretical framework, an explanation of how rigor was
attained, and informed consent. However, the results of this
study are beneficial because they have narrowed down different
organizational factors that could be impacting CLABSI rates.

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Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

This article is valuable because the results bring light to another
aspect of the central line bundle that is important in
maintaining low CLABSI rates, which is the role of the
administrators.
First Author
(Year)/Qualifications

Background/Problem
Statement

Conceptual/theoretical
Framework

Merrill et al. (2014). Katreena Merrill, Sharon Sumner,

Lorraine Linford have all published research on central lineassociated blood stream infections (CLABSIs). Katreena
Merrill has a PhD, and all of the authors are registered nurses.
These authors are qualified to conduct research on CLABSIs.
The researchers did a wonderful job of giving background
information about CLABSIs. The problem statement in the
article is that the amount of CLABSIs in the United States and
abroad is very large (Merrill, Sumner, Linford, Taylor, &
Macintosh, 2014).
The purpose of this study is to analyze the effect of universal
IV needless connector disinfectant cap implementation on the
rate and type of CLABSI and estimated costs in a large tertiary
care center using a standard central line bundle (Merrill et al.,
2014, p. 1275).
A conceptual/theoretical framework was not identified.

Design/
Method/Philosophical
Underpinnings

Quantitative
Quasi-experimental
No philosophical underpinnings were mentioned.

Sample/ Setting/Ethical
Considerations

The study was conducted in a 430-bed tertiary care trauma I

center in the U.S. Mountain West (Merrill et al., 2014). A luerlock disinfectant cap with 70% alcohol was implemented in all
patients (newborn to adults) with peripheral and central lines
residing on 13 inpatient units at 1 hospital beginning in January
2012 (Merrill et al., 2014, p. 1275).

Major Variables Studied

(and their definition), if

The researchers did not mention how the subjects were

protected from harm or how confidentiality was maintained.
The hospital product review committee and the institutional
review board granted permission for the use of the disinfectant
cap for this study.
Intravenous (IV) needless connector
disinfectant caps- (Curos Disinfecting Port

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Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

appropriate

Measurement Tool/Data
Collection Method
Data Analysis

Findings/Discussion

Protector, Curos, San Diego, CA; a plasticthreaded device that contains 70% isopropyl
alcohol (Merrill et al., 2014)
Presence of CLABSI- The presence of
CLABSI was defined as a primary laboratory
confirmed bloodstream infection in a patient
with a central line at time of (or within 48
hours prior to) the onset of symptoms and
the infection is not related to an infection
from another site (Merrill et al., 2014, p.
1276).
CLABSI rates- The rate of CLABSI was
calculated per 1,000 central line catheter
days (Merrill et al., 2014, p. 1276).
Costs of CLABSIs
Disinfectant cap compliance- The
number of disinfectant caps present was
divided by the number of total available
needless connectors to result in an overall
compliance rate per central line patient
(Merrill et al., 2014, p. 1275).
Compliance was determined by audits conducted 1-2 times per
week beginning in February 2012 and lasting throughout the
study period (Merrill et al., 2014, p. 1275).
Data were analyzed using IBM SPSS version 22.0 (SPSS Inc,
Chicago, IL) (Merrill et al., 2014, p. 1276). A generalized
linear model using a Poisson distribution was fit to determine if
there was a significant difference in CLABSI rates following
implementation of the disinfectant cap (Merrill et al., 2014, p.
1276).
The rate of CLABSI per 1,000 central line days decreased
following implementation of the disinfectant cap (before
implementation: mean +/- SD, 1.5 +/- .37) (after
implementation: mean+/- SD, .88 +/- .62) (Merrill et al., 2013,
p. 1276).
CLABSI rates decreased with the implementation of a
disinfectant cap, and these results are statistically significant.
The incidence rate ratio (IRR=.577, P=.004) for implementing
the disinfectant caps was statistically significant indicating that
the rate of patient infections decreased by >40% with the use of
the disinfectant cap (Merrill et al., 2014, p. 1276).

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Running head: AN INTEGRATIVE REVIEW: CENTRAL LINE INTERVENTIONS

Appraisal/Worth to
practice

The authors left out very important aspects of a research article,

such as major parts of their methodology and ethical
considerations. However, even with such parts missing, the
article is still very valuable. This article is valuable because
there was a statistically significant decrease in CLABSI rates
after the implementation of disinfectant caps.

24