NURS 411_Codi_Leggett Assignment 6

Running head: CENTRAL LINE PROTOCOL 1

Baylor Scott & White Central Line Maintenance Protocol

Codi Leggett

NURS 411: Evidence-Based Practice for Nurses

May 3, 2016

Abstract

CENTRAL LINE PROTOCOL 2

Baylor Scott & White Health (BSWH) has a central line protocol which provides direction for

providers in how to administer, access, maintain, and flush. These guidelines should be

evidence-based practices, but research should be evaluated to determine if the protocol is up to

date with the evidence. Evidence was found that supports the protocol is following recent

evidence-based practice. However, enforcement is the greatest concern for this protocol because

the criteria is evidence-based, but it cannot prove its effectiveness without proper adherence to

the protocol.

Baylor Scott & White Central Line Maintenance Protocol


“Seven years of zero central-line-associated bloodstream infections” is what the Sutter

Roseville Medical Center PICC team has achieved after implementing their central line bundle

checklist and protocols (Harnage, 2012). If all facilities could achieve this kind of successful

infection prevention, it would completely change this area of medicine in the future. All hospitals

and healthcare facilities are supposed to have policies and protocols in place to keep the

healthcare providers in line with appropriate practices. A specific protocol from the Baylor Scott

& White Health (BSWH) guidelines was chosen to evaluate and determine if it follows best

practices according to research evidence, especially since this facility strives to use evidence-

based practice (EBP) (2011/2015). The BSWH protocol describes the guidelines for cleaning the

catheter ports, flushing the tubing (how and when), and requirements for changing the dressing

and maintaining the catheters. The following contains a synthesis of the evidence from several

scholarly articles, a summary of the BSWH protocol, and together both will be used to determine

best practice for central line protocols. Additional evidence can be found in Appendix B. It is

important to look at the evidence for the protocol to ensure the facility is using best practices,

and to prevent bloodstream infections which are often caused by lack of adherence to protocols

and best practices. The synthesis of evidence will be used to determine the validity of the

protocol and then compare it to what is used at the BSWH facility to see if it is supported by best

practice evidence. The strength of the evidence will be determined and then recommendations

will be made for practices based on the evidence.

Overview of the Practice Guideline

Baylor Scott & White Health provides nurses and other qualified personnel with

the “Maintaining, Accessing, and Flushing Central Lines Protocol” (BSWH, 2011/2015). The

policy, protocol, and associated charts for this can be found attached in Appendix A (BSWH,


2011/2015). This protocol provides direction for the best way to perform care of central lines at

the BSWH hospital in College Station, Texas. They provide assessment frequency, how often

dressings need to be changed and which techniques to use. The hospital protocol utilizes a chart

for nurses to easily refer to proper flushing, maintenance, and accessing for each equipment type

(BSWH, 2011/2015). Nurses can use this protocol and tool to implement EBP when caring for

patients that have a central line. The target population is chronically ill patients or patients that

need more long term venous access for their treatment. The goal of this protocol is to reduce

infections by implementing evidence-based practice for the nurses of this facility to use when

caring for central lines (BSWH, 2011/2015). Central lines provide direct access to the blood in

the heart, and preventing infection from developing and spreading systemically is crucial. The

policy superseding this protocol stresses the use of EBP at Baylor Scott & White and references

are provided, however they are not easily accessible because they are formally cited in another

section of the hospital protocol database. It would be useful to have the resources more

accessible in order to check the validity of the sources. This protocol originated in January 2011,

and was last reviewed/revised in May 2015. Although this is recent, new research could have

developed within one year (BSWH, 2011/2015).

Synthesis of the Evidence

In a meta-analysis regarding prevention of central line infections, it was found that

quality improvement interventions reduced the rate of central line infections. Specifically, the

bundle and checklist intervention, along with education, evaluated before and after, showed

significant results for decreasing the rate of central-line associated infections (Blot, Bergs,

Vogelaers, Blot, & Vandijck, 2014). Although each bundle and checklist can be different, most


included hand hygiene, chlorhexidine skin antiseptics, and sterile barrier precautions, all of

which contributed to the decreased rate overall by implementing all of these to prevent infection.

The meta-analysis is an ideal supporting article for the Central Line Protocol at Baylor

Scott & White Health (BSWH) because they utilize a bundle and checklist system to ensure

adequate protocol, and educate the patient before obtaining informed consent to the procedure

(BSWH, 2011/2015). Forty-one before-and-after studies revealed that bundle and checklist

interventions, along with education decreased the rate of central-line associated infections with

significance of P<.001 vs checklists alone were only P=0.3 (Blot, Bergs, Vogelaers, Blot, &

Vandijck, 2014). The combined multi-angle improvement technique proved a decreased rate

from 1.5 to 0 central line infections per 1000 catheter days (Blot, Bergs, Vogelaers, Blot, &

Vandijck, 2014). This article proves very effective in supporting the BSWH protocol.

A quantitative study discussed the effects of infection control by using a scrub-the-hub

technique or a disinfection cap when caring for central and peripheral IV lines. They revealed

that if only one item was used, the disinfection cap was the most effective in preventing

infection, however, if both techniques were used together, the disinfection rate could

significantly be reduced (DeVries, Mancos, & Valentine, 2014).

The BSWH central line protocol requires use of a disinfection cap on the tubing and

scrubbing the hub before using the line for anything (BSWH, 2011/2015). This is supported by

DeVries, Mancos, and Valentine’s quantitative study that reveals the rate of bloodstream

infections was reduced by 50% in central lines by using a disinfection cap (2014). It is also

suggested that if the two interventions are used together that the reduction in infection rate could

be greater than 50% (DeVries, Mancos, & Valentine, 2014).


Bloodstream infections have an increased risk when errors occur during the insertion of

the line, according to Barreto and colleagues (2013). They completed a quantitative study to

evaluate a correlation between the number of errors in placing the devices and the rate of

bloodstream infections in patients (Barreto et al., 2013). Errors range from not cleaning

adequately and not wearing gloves, to any action that swayed from the protocol of the facility

being observed (Barreto et al., 2013).

It is crucial to minimize errors when caring for central lines because mistakes can affect

the safety of patients and increase the risk of infections when using central lines. The BSWH

central line protocol requires properly trained professionals and proper technique to be employed

during central line insertion and maintenance (BSWH, 2011/2015). This article supports the

protocol by revealing that the more errors that occurred, the higher the chance of bloodstream

infection occurring with significance (r=0.845 and p=0.000) (Barreto et al., 2013). The use of

correct techniques, education, and experience can help eliminate errors and increased infection

risk.

Even though we hope all nurses and providers follow evidence-based practice, there are

some things that interfere with compliance of guidelines. According to Gurses and colleagues’

qualitative study, five types of ambiguity exist: task, expectation, responsibility, method, and

exception (2008). Additionally, heavy workload, understaffing, disagreement, costs of

implementation, forgetfulness, and lack of supplies all contribute to the increase of infections

and medical errors (Gurses et al., 2008).

Compliance with guidelines also protects the safety of patients and staff. Without it, the

risk of infection increases. A qualitative study revealed that five types of ambiguity (task,

expectation, responsibility, method, and exception) affect compliance with protocols and can


cause an increase in infection rates (Gurses et al., 2008). This supports the BSWH protocol

because it reinforces the need to follow the protocol itself because when ambiguity affects the

compliance, infection rates increase (BSWH, 2011/2015). Gurses et al. article also provides

insight for the BSWH facility to observe their contributors to non-compliance such as workload,

number of staff, costs, and the amount of supplies to see if they need changes to help protect the

safety of patients (2008).

Since occlusion of an IV catheter can lead to infection, vessel irritation, and embolus, a

quantitative study was completed to determine if the beginning of occlusion in catheters could be

predicted to decrease complications (Wolf et al., 2015). Catheter-resistance monitoring was used

to predict occlusion in catheters, and was found to be capable of predicting possible occlusions

(Wolf et al., 2015). Saline flushes are often used to ensure patency, but by measuring the

pressure, nurses could begin to predict the beginning of an occlusion before infection occurs.

Catheter occlusion can lead to infection, and the BSWH central line protocol provides

specific instructions for flushing techniques and frequency to prevent occlusion and infection

(BSWH. 2011/2015). A quantitative study was performed to determine the predictability of

occlusion using saline flushes and revealed p<0.01 prediction of occlusion within 10 days. The

study supported the BSWH protocol for flushing, but refuted it by displaying the need to add

catheter-resistance monitoring to the protocol as well in addition to flushing before and after use

of any line (Wolf et al., 2015).

Recommendations for Practice

The BSWH central line protocol follows a bundle checklist system for maintaining,

accessing, and flushing central lines. Blot et al. (2014) compares different improvement

interventions, and found that bundles or checklists revealed the largest decrease in infection rate.


This Level I study (Polit & Beck, 2014, p. 22) provides useful evidence because it utilizes a

systematic review followed by a meta-analysis of multiple articles. It reveals that bundles and

checklists almost always include the major aspects that contribute to decreased infections, which

in this study, resulted in zero catheter infections in 1000 days (Blot, Bergs, Vogelaers, Blot, &

Vandijck, 2014). The evidence supports the checklists used for the BSWH protocol, and should

continue to be used in practice.

Scrubbing the hub or use of a disinfection cap is what is considered appropriate in the

BSWH protocol (2015). DeVries, Mancos, and Valentine (2014) reveal that the disinfection cap

decreased infection rates by 50% which supports the BSWH protocol (2011/2015). However,

this level III, prospective, observational study (Polit & Beck, 2014, p. 23) reveals that the use of

both the disinfection cap and scrubbing the hub would be the most beneficial based on the trial

(DeVries, Mancos, & Valentine, 2014). Although not the strongest level of evidence, the drastic

significance of the results reveal the importance of implementing these two techniques together

which would be the best recommendation for practice.

Errors while administering central lines can greatly affect the risk of infection according

to Barreto et al. (2013). This level IV, longitudinal, prospective study (Polit & Beck, 2014, p. 23)

shows the connection of administration errors and maintenance errors increase infection risk

(Barreto et al., 2013). This supports the BSWH protocol (2011/2015) because it requires

specifically trained personnel to administer central lines, and requires maintenance guidelines to

prevent infection. The best recommendation is to enforce the protocol in place at BSWH.

Another level IV, prospective study (Polit & Beck, 2014, p. 23) revealed that catheter

occlusion can be predicted and prevent the development of a bloodstream infection (Wolf et al.,

2015). The BSWH protocol (2011/2015) contains flushing recommendations to prevent


occlusion, but it does not measure pressures to predict occlusions (Wolf et al., 2015). This study

supports the BSWH protocol criteria of flushing, but could also be improved by adding pressure

measurements to the flushing protocol.

Gurses et al. (2008) utilized a grounded theory level VII study (Polit & Beck, 2014, p.

48) to evaluate the ambiguity that causes protocols to not be followed and determine the social

influences on protocol adherence. Although this study does not directly support the criteria

within the protocol, it supports the need for the protocol as a whole, and encourages the

recommendation of eliminating ambiguities which interfere with protocol adherence (Gurses et

al., 2008). If the protocol is followed, the risk for infection in central lines will be reduced, and it

is recommended that the facility enforce its protocol that is in place.

Conclusion

These articles are all supporting the Baylor Scott & White Health central line protocol,

and provide evidence that the protocol is following evidenced based practice. Not every criteria

within the protocol is explained in depth with evidence, but these articles validate many of the

important aspects within the protocol. Some of the evidence focuses on ensuring that the

protocol is actually enforced and utilized, because even though many protocols exist, they do not

provide benefits unless they are utilized the way they are written. Having evidence to support the

protocol ensures patients receive care that has demonstrated proven results. Overall, the best

recommendation is to adhere to the protocol that already exists, specifically utilizing the

checklist, the hub disinfection, and the flushing techniques. According to Harnage (2012),

bundles and checklists, if they are evidence-based and are followed as written by providers, can

have the potential to almost completely eradicate central line infections. More research should be


completed to evaluate the best practice of each specific criteria of the protocol, but overall the

BSWH protocol proves to be following best practice.


References

Baylor Scott & White Health. (2015). Maintaining, accessing, and flushing central lines protocol.

Central line management (X.1079.3.SW.059). (pp. 1-4). (Original work published 2011)

Blot, K., Bergs, J., Vogelaers, D., Blot, S., & Vandijck, D. (2014). Prevention of central line–

associated bloodstream infections through quality improvement interventions: A

systematic review and meta-analysis. Clinical Infectious Diseases, 59(1), 96-105.

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 7p.

doi:10.1016/j.java.2014.02.002

Filgueira Gouveia Barreto, A., YurÃ AraÃºjo Farias Dias, T., Fernandes Costa, I. K., de Sousa

Martins Melo, G., Elza Oliveira de MendonÃ§a, A., & de Vasconcelos Torres, G. (2013).

Infection of central venous catheter and the non-compliance of protocols in the intensive

care unit. Journal of Nursing UFPE / Revista de Enfermagem UFPE, 7(2), 430-437 8p.

doi:10.5205/reuol.3073-24791-1-LE.0702201314

Gurses, A. P., Seidl, K. L., Vaidya, V., Bochicchio, G., Harris, A. D., Hebden, J., & Xiao, Y.

(2008). Systems ambiguity and guideline compliance: A qualitative study of how

intensive care units follow evidence-based guidelines to reduce healthcare-associated

infections. Quality & Safety in Health Care, 17(5), 351-359.

doi:10.1136/qshc.2006.021709

Harnage, S. (2012). Seven years of zero central-line-associated bloodstream infections. British

Journal Of Nursing, S6-S12 1p.

Polit, D. F., & Beck, C.T. (2014). Essentials of nursing research: Appraising evidence in nursing

practice (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.


Wolf, J., Tang, L., Rubnitz, J. E., Brennan, R. C., Shook, D. R., Stokes, D. C., & ... Flynn, P. M.

(2015). Monitoring central venous catheter resistance to predict imminent occlusion: A

prospective pilot study. Plos ONE, 10(9), 1-15. doi:10.1371/journal.pone.0135904


Appendix A: Protocol





Appendix B: Evidence GridCitation (APA) Purpose Sample Design Measurement Results/Conclusions Level of

EvidenceBlot, K., Bergs, J., Vogelaers, D., Blot, S., & Vandijck, D. (2014). Prevention of central line–associated bloodstream infections through quality improvement interventions: A systematic review and meta-analysis. Clinical Infectious Diseases, 59(1), 96-105.

Determine the effects of quality improvement interventions for central lines reduce bloodstream infection rates based on different studies and different interventions.

N= 584 ICUs

Article samples:634 screened75 articles assessed for eligibility63 articles in systematic review43 studies included in meta-analysis

Intervention category and number of studies:Education (33), training (4), feedback (20), clinical reminders (15), bundle (11), checklist (18), empowerment to stop procedure (10), surveillance (12), leader designation (11), prepackaging (16), infrastructure changes (2), organizational changes (4)

Systematic review followed by random-effects meta-analysis

(Eligible studies used before-after, interrupted time series (ITS), controlled before-after, nonrandomized controlled trial, and randomized controlled studies) Before-after and ITS are preferred

27 questions were used to evaluate the validity and power of each study

the DerSimonian-Lairdestimator obtained odds ratios forrate reductions. The Higgins I2 test was predefined to quantifyheterogeneity (I2 ≤ 25% for low, 25% < I2 < 50% for moderate,and I2 ≥ 50% for high), and funnel plots assessed publicationbias; subgroup analysis through meta-regression compared checklist interventions.

Quality improvement interventions reduce central-line infection rates.

The infection rate was decreased the most with bundles or checklist interventions.

Feedback intervention was the least improvement rate, however significant rate reduction in infection still occurred.

Further research should be done to determine requirements of successful adaptation of the interventions.

Level I


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 7p. doi:10.1016/j.java.2014.02.002

Determine if the use of a disinfection cap decreases the rate of bloodstream infections in central/PICC and peripheral lines.

3 intensive care units for a 3-month span (all patients with a central/PICC or peripheral line)

Prospective observational study that is not randomized

Bloodstream infection rate was tracked for the 3 months and no infections occurred during the 3 month trial. Pre-intervention and post-intervention rates were compared later to determine the reduction rate with the intervention.

The combined reduction rate for central lines and peripheral IV lines was decreased by 50.0%.

Use of the disinfection cap offers protections that “scrub-the-hub” cannot provide alone.

The disinfection cap used with the “scrub-the hub” technique together shows a significant bloodstream infection rate in central lines and peripheral lines (P < .000001).

Level III

Filgueira Gouveia Barreto, A., YurÃ AraÃºjo Farias Dias, T., Fernandes Costa, I. K., de Sousa Martins Melo, G., Elza Oliveira de MendonÃ§a, A., & de Vasconcelos Torres, G. (2013). Infection of central venous catheter and the non-compliance of protocols in the intensive care unit. Journal of Nursing UFPE / Revista de Enfermagem UFPE, 7(2), 430-437 8p. doi:10.5205/reuol.3073-24791-1-LE.0702201314

Determine if central venous catheter infections are being caused by non-compliance of staff with protocol of insertion or maintenance of the line.

N= 31 patients undergoing central venous catheter insertion

Longitudinal, prospective study

Researchers observed insertion and maintenance of central venous catheters and considered errors that occurred for both insertion and maintenance.

to compare themean scores of errors in the procedure ofinserting and maintaining the catheter, andthe Spearman Correlation test (r <0.50 = poor,0.50 ≤ r ≥ 0, 74 = moderate, r ≥ 0.75 = strong)

The higher number of errors that occur during the insertion and maintenance of central catheters revealed increased risk for infection. (2-9 errors resulted in infection & 0-5 errors did not result in infection)

-risk ofinfection at the insertion time:strong and significant (r = 0.845 p = 0.000)

-risk of infection inMaintenance: moderate and significant(r = 0.551 p = 0.001)

Level IV


Gurses, A. P., Seidl, K. L., Vaidya, V., Bochicchio, G., Harris, A. D., Hebden, J., & Xiao, Y. (2008). Systems ambiguity and guideline compliance: A qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. Quality & Safety in Health Care, 17(5), 351-359. doi:10.1136/qshc.2006.021709

Evaluate if evidence-based practices are being followed by health care staff to prevent infections caused by central venous catheters, ventilator-assisted pneumonia, surgical site infections, and catheter associated UTI. What causes protocol to not be followed by staff.

N=20Sample of 3 physicians, 2 residents, 6 nurses, 3 quality improvement coordinators, 2 infection control practitioners, 2 respiratory therapists, and 2 pharmacists

Grounded Theory 20 semistructured interviews

(14-66 min interviews)

Systems ambiguity plays a major role in non-compliance of evidence-based guidelines.

Things that contribute to non-compliance are heavy workload, understaffed, disagreement, costs of implementation, forgetfulness, lack of supplies and equipment.

There are 5 types of ambiguity that exist: task, expectation, responsibility, method, and exception. All of which contribute to hospital acquired infections, medical errors and an obstacle for learning.

Level VII

Wolf, J., Tang, L., Rubnitz, J. E., Brennan, R. C., Shook, D. R., Stokes, D. C., & ... Flynn, P. M. (2015). Monitoring central venous catheter resistance to predict imminent occlusion: A prospective pilot study. Plos ONE, 10(9), 1-15. doi:10.1371/journal.pone.0135904

Determine the feasibility, acceptability, and efficacy of monitoring central venous catheters for signs of occlusion (resistance).

n=10 pediatric patients over 113 central-resistance monitoring visits

Prospective study Catheter-resistance monitoring was performed weekly for up to 12 weeks. Normal saline was injected while inline pressure rates were measured using a syringe pump with an incorporated pressure-sensing inducer

Catheter occlusion occurred frequently and CRM was helpful in predicting these event.

Some analysis showed p<0.01 prediction of occlusion within 10 days; another predicted p=0.01 prediction of occlusion within 10 days.

The sensitivity and specificity are reasonable but imperfect.

Level IV

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NURS 411_Codi_Leggett Assignment 6