Running Head: PICOT QUESTION CENTRAL LINE-ASSOCIATED INFECTIONS
PICOT Question Central Line-Associated Infections
Courtney Pribonic
Kaplan University
3/5/2017
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PICOT QUESTION CENTRAL LINE-ASSOCIATED INFECTIONS
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Introduction
Patients hospitalized in intensive care units (ICU) sometimes suffer from central lineassociated infections (CLAI). These illnesses are mostly caused by microorganisms which act
on the central venous catheters. As a way of eliminating this adverse effect, evidence based
care has implemented various intervention techniques most of which are grouped as a bundle
that comprises of various individual activities. This paper seeks to identify a suitable
evidence-based care intervention for preventing CLAI among adult patients hospitalized in
ICUs.
PICOT Question
In formulating and developing this research, a systematic review was mainly done on
Cochrane database on studies tackling care and maintenance of the CVC published between
2010 and 2017, Scopus, PubMed, and the web of science. This was founded on the PICOT
strategy question;
“What are the best CLAI-related preventive and intervention measures implemented
in adult patients who are hospitalized in an ICU?”
The outcomes of the research after analysis presented bundles which included
elements such as maximal barrier precautions and hand hygiene. Essentially, these were in
the form of multidimensional strategies and programs such as impregnated bandages and
catheters as well as the commitment of the staff to keeping facilities infection free (JC et. al.,
2011).
Treatment of critically ill patients depends on the Central Venous Catheters (CVC) by
a significant percentage. For instance, in intensive care units, techniques such as the use of
invasive devices and diagnostic procedures are utilized to trigger particular patient
PICOT QUESTION CENTRAL LINE-ASSOCIATED INFECTIONS
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complications like the health associated infections (HAI). However, there is a significant
challenge in the ICU regarding prevention and control of nosocomial infections as a result of
microorganisms (Blot, et.al, 2014). These organisms are usually multiresistant and create the
need to use broad spectrum antibiotics. Therefore, the invasive procedures used in ICU to
some extent complicate the control of infections. In this regard, the central line-associated
infection (CLAI) is the major complication that incurs to the central venous catheters.
The current intervention procedures for CLAI are in the form of bundles which are
used wholesomely. This means that each package is implemented by carrying all the activities
included in it and not just selecting a few. One of the commonly utilized technique is the care
package. This bundle contains five elements which include; clean skin preparation with
chlorhexidine, hand hygiene, avoidance of femoral sites, elimination of unnecessary catheters,
and sterile barrier precautions during CVC. As per JC et al. (2011) methodology, the bundle
was implemented along with a strong safety culture, education, and organizational strategies.
Moreover, during implementation, information was collected for calculating the rates of
infection and monitoring the level of adherence to hygiene. The results obtained a 2.d level of
evidence.
Another intervention is the quality technique which comprises of two different
bundles. This particular response also has a strong focus on hand hygiene, and the two bundles
included are the CVC insertion and CVC maintenance (Blot, et.al, 2014). CVC insertion has
these elements; femoral vein avoidance, skin preparation with chlorhexidine, and maximal
sterile barrier. On the other hand, the CVC maintenance bundle comprises of daily checks to
ascertain the needs of CVC insertion, connection checking and assessment without the use of
needles, and suitable bandage replacement techniques. Blot, et.al (2014) while implementing
these interventions, he coupled the elements with educational programs which were
PICOT QUESTION CENTRAL LINE-ASSOCIATED INFECTIONS
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disseminated via teaching videos, conferences, and surveillance processes. The evidence level
attained was 2.d.
The study by the Institute for Healthcare Improvement (IHI) as stated by Perin et.al
(2016) focused on the significance of implementing all significant elements that are included
in all bundles. In this regard, the study proposed that a list is used to monitor and evaluate the
applicability of the elements in caring for ICU adult patients. From the study’s finding, it was
found that when compliance and adherence to efficient implementation of all items of a bundle
is high, the rates of infection within adult patients in ICU reduces significantly. The EBP level
of evidence of this research was 3e. This technique is similar to the use of multidimensional
approach in preventing CLAI in ICU patients. This includes combining elements from various
bundles and applying them at once (Berenholtz, et.al, 2014). In practice, the elements
considered most includes combining a bundle of intervention, outcome surveillance,
education, infection and feedback rates, performance feedback, and process surveillance.
Their level of evidence is often 2.c.
This study shows that different types of care bundles can be used as EPB Interventions
for Prevention of central line-associated infections in ICU/CCU. However, both of them
revolve around having high levels of hygiene. This means that microorganisms responsible
for causing various central line-associated infections in ICU such as complications of the
central venous catheters are propagated via unhygienic practice (Latif, et.al, 2015). However,
it is evidence that the care bundle comprises of elements which are vital for preventing these
infections. However, the elements on their own are not highly efficient, and they need to be
coupled with strong safety culture, education, enabling organizational strategies, strong staff
engagement, and surveillance processes.
PICOT QUESTION CENTRAL LINE-ASSOCIATED INFECTIONS
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Conclusion
The three studies made offer ways to prevent central line-associated infections among
patients hospitalized in ICUs. Two of the studies showed that implementation of good care
practice leads to a reduction in rates of central line-associated infections in ICU/CCU. In this
regard, the best care measures come from the bundle which includes CVC maintenance and
insertion and vital strategies such as engagement and education of the staff, surveillance
process, and safety culture. These are features associated with the care bundle. Therefore, it
is evidence that the care bundle which comprises insertion cleaning with chlorhexidine,
femoral site avoidance, strict hand hygiene, and catheter removal as soon as it becomes
unnecessary is the best intervention for preventing CLAI among adult patients hospitalized in
intensive care units.
References
Berenholtz, S. M., Lubomski, L. H., Weeks, K., Goeschel, C. A., Marsteller, J. A., Pham, J.
C., ... & Yang, T. (2014). Eliminating central line–associated bloodstream infections:
a national patient safety imperative. Infection Control & Hospital Epidemiology,
35(01), 56-62.
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, ciu239.
JC, O., GL, S., N, S., O’Horo, J., Silva, G., & Safdar, N. (2011, January 1). Anti‐infective
locks for the treatment of central line‐associated bloodstream infection: A systematic
review and meta‐analysis (Provisional abstract). Retrieved March 6, 2017, from
http://onlinelibrary.wiley.com/o/cochrane/cldare/articles/DARE12011007506/frame.html
PICOT QUESTION CENTRAL LINE-ASSOCIATED INFECTIONS
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Latif, A., Kelly, B., Edrees, H., Kent, P. S., Weaver, S. J., Jovanovic, B., ... & Berenholtz, S.
M. (2015). Implementing a Multifaceted Intervention to Decrease Central Line–
Associated Bloodstream Infections in SEHA (Abu Dhabi Health Services Company)
Intensive Care Units: The Abu Dhabi Experience. infection control & hospital
epidemiology, 36(07), 816-822.
Perin, D. C., Erdmann, A. L., Higashi, G. D. C., & Sasso, G. T. M. D. (2016). Evidence-based
measures to prevent central line-associated bloodstream infections: a systematic
review. Revista Latino-Americana de Enfermagem, 24.
PICOT Question Central LineAssociated Infections
Courtney Pribonic
Kaplan University
3/25/2017
Introduction
This data analysis focuses on
• Explaining key clinical questions for searching in the database.
• Clearly defining database findings and outputs.
• Systematic review of evidence levels.
• Descriptive analysis of the study based on the PICOT question.
PICOT Questions
The studies PICOT question was
• “What are the best CLAI-related preventive and intervention measures
implemented in adult patients who are hospitalized in an ICU?”
The development of the PICOT question was based on;
• There are high chances of ICU patients suffering from CLAI.
• Most CLAI are caused by microorganisms.
• CLAI causing microorganisms act on the central venous catheters.
Evidence-Based PICOT Questions
• Population: adult patients admitted in ICU.
• Intervention: The physician’s role in ensuring clean and hygienic
conditions in the ICU.
• Comparison: hospital management’s role in educating physicians and
patients on how to limit the spread of CLAI especially through utilisation
of proper care bundles.
• Outcome: there are better elimination chances when physicians and
nurses are involved in implementing care bundles for minimizing CLAI in
ICU
• Time: perioperative time can include a week worthy of training and
teaching.
Database Search Questions
• What is the CLAI prevalence level in adult patients admitted in ICU?
• What are the probable risky factors for CLAI in adult patients at a
hospital?
• What are the major types of CLAI in adult patents?
• How do microorganisms survive in ICU and other hospital
environments?
• What are the most effective intervention measures for CLAI in
hospitals?
Databases Used
These nursing and health information databases were utilised;
• Cochrane database. -Care and maintenance of the CVC
• Scopus. Care bundles for preventing CLAI
• PubMed. CLAI risky factors
• Web of science. Other evidence based practise information.
The resech limited itself to sources developed between 2010 and 2015.
Database Results
• About 23.3% of adults admitted in ICU develop other complications.
• Most risky factors for CLAI include general hygiene, contained air and
water systems, antibiotic resistance.
• Current causes of CLAI are Microbial presence and antibodies resistance
• Common types of CLAI include; Catheter-associated urinary tract
infections, Surgical site infections, Bloodstream infections, Pneumonia,
Clostridium difficile
• Enhancement of hospital hygiene, proper antibiotics selection, clean air
and water systems, improved knowhow by patients and physicians are
some of the best CLAI intervention techniques.
Statistical Database Results
• There is at least one CLAI infection daily in one out of 25 hospitals.
• As per the CDC (2014), there was a 50% reduction in catheter-associated urinary
tract infections (CAUTI) between the years 2010 and 2014.
• No reduction in catheter-associated urinary tract infections (CAUTI) between 2010
and 2014
• There was a general decline in ICU CLAI infection between 2013 and 2014. This
included
✓17% reduction in surgical site infections (SSI),
✓8 % reduction in hospital-onset Clostridium difficile (C. difficile),
✓13 % reduction in hospital-onset methicillin-resistant.
Research Strategy
Descriptive Study
• Preliminary observation were done on database
sources.
• The study utilized a case study approach.
• Hospitals were selected randomly.
• All the Hospitals were from USA.
• All hospitals had specialised care units such as the
ICU
Statistical Output
• The total number of hospitals randomly selected were 27.
• The groping of the hospitals was based on the outcomes of the
outputs from the database search.
• The database search outcomes were subjected to group (chain-P)
factor analysis rating.
• The study analysed the 27 hospitals based on the chain-P group
analysis.
• The results showed that 20 of the 27 individual P-technique
analyses had witnessed signs of hospital related infection.
Level of Evidence
• Level one
• level two.
Involved searching information Evidence was obtained from the
in these databases
✓ Cochrane database
✓Scopus,
✓PubMed,
✓ the web of science.
✓the CDC (centre for disuse
control) website.
✓Selected subject hospital’s
websites.
Conclusion And Recommendations
• CLAE and hospital associated infections are present in the health care
facilities.
• Specific avoidance based care need to be adopted to solve CLAI issues.
• Best CLAE interventions includes
✓Implementation of the care bundle
✓Utilizing preventive nursing practice.
• Despite the CLAE dominance, the reported reduction of ICU related
hospital infection offers hope for achieving zero percent CLAI in
hospitals.
References
• JC, O., GL, S., N, S., O’Horo, J., Silva, G., & Safdar, N. (2011, January 1). Anti‐infective locks for
the treatment of central line‐associated bloodstream infection: A systematic review and
meta‐analysis (Provisional abstract). Retrieved March 6, 2017, from
http://onlinelibrary.wiley.com/o/cochrane/cldare/articles/DARE-12011007506/frame.html
• Latif, A., Kelly, B., Edrees, H., Kent, P. S., Weaver, S. J., Jovanovic, B., ... & Berenholtz, S. M.
(2015). Implementing a Multifaceted Intervention to Decrease Central Line–Associated
Bloodstream Infections in SEHA (Abu Dhabi Health Services Company) Intensive Care Units: The
Abu Dhabi Experience. infection control & hospital epidemiology, 36(07), 816-822.
• Perin, D. C., Erdmann, A. L., Higashi, G. D. C., & Sasso, G. T. M. D. (2016). Evidence-based
measures to prevent central line-associated bloodstream infections: a systematic review. Revista
Latino-Americana de Enfermagem, 24.
• Berenholtz, S. M., Lubomski, L. H., Weeks, K., Goeschel, C. A., Marsteller, J. A., Pham, J. C., ... &
Yang, T. (2014). Eliminating central line–associated bloodstream infections: a national patient safety
imperative. Infection Control & Hospital Epidemiology, 35(01), 56-62.
• 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, ciu239
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