Central Line-Associated Bloodstream Infections

CLABSIs

Central Line-Associated Bloodstream Infections

Instructions:-A.  Write a brief summary (suggested length of 2–3 pages) of the significance and background of a healthcare problem by doing the following:

1.  Describe a healthcare problem.

2.  Explain the significance of the problem.

3.  Describe the current practice related to the problem.

4.  Discuss how the problem impacts the organization and/or patient’s cultural background.

B.  Complete the attached “PICO Table Template” by identifying all the elements of the PICO.

1.  Develop the PICO question.

C.  Describe the search strategy (suggested length of 1–2 pages) you used to conduct the literature review by doing the following:

1.  Identify the keywords used for the search.

2.  Describe the number and types of articles that were available for consideration.

a.  Discuss two research evidence and two non-research evidence sources that were considered (levels I–V).

D.  Complete the attached “Evidence Matrix” to list five research evidence sources (levels I–III) from scholarly journal sources you locate in major medical databases.

Note: Four different authors should be used for research evidence. Research evidence must not be more than five years old.

Note: You may submit your completed matrix as a separate attachment to the task or you may include the matrix within your paper, aligned to APA standards.

E.  Explain a recommended practice change (suggested length of 1–3 pages) that addresses the PICO question within the framework of the evidence collected and used in the attached “Evidence Matrix.”

F.  Describe a process for implementing the recommendation from part E (suggested length of 2–3 pages) in which you do the following:

1.  Explain how you would involve three key stakeholders in the decision to implement the recommendation.

2.  Describe the specific barriers you may encounter in applying evidence to practice changes in the nursing practice setting.

3.  Identify two strategies that could be used to overcome the barriers discussed in F2.

4.  Identify one indicator to measure the outcome related to the recommendation.

G.  Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.

Solution.

Central Line-Associated Bloodstream Infections

Introduction

Nosocomial infections, also known as hospital-acquired infections, are infections which are contracted from the staff or environment of a healthcare facility. Nosocomial infections can be spread to a patient through a number of means. These infections pose a very significant and increasing threat to modern medicine and health care since estimates from the Centers for Disease Control and Prevention (CDC) place the number of patients who contract such infections at two million annually. It has even been estimated that nosocomial infections may be causing more deaths per year than AIDS or breast cancer (Magner, 2009, p. 67).

Central Line-Associated Bloodstream Infections

Definition

Nosocomial infections, however, comprise a number of different, more specific types of hospital-acquired infections, classified accord to the means of infection or the major organ system affected. The specific hospital-acquired infection that shall form the focus of this paper is the central line-associated bloodstream infection. Central lines are intravascular catheters that end at or close to the heart or in one of the great vessels and are used for blood withdrawal, infusion, or hemodynamic monitoring (Corrigan, et al., 2010, p. 221). For defining and reporting central line infections, the CDC considers the following as great vessels: external iliac veins, aorta, subclavian veins, pulmonary artery, internal jugular veins, superior vena cava, inferior vena cava, common femoral veins, and brachiocephalic veins (Corrigan, et al., 2010, p. 221). The umbilical vein/artery in neonates is also considered a great vessel. While an introducer is considered as a central line, pacemaker wires as well as other nonlumened devices inserted into the heart or central blood vessels do not qualify as central lines since fluid are not withdrawn, infused or pushed through such devices.

Permanent central lines comprise of tunneled catheters, which includes implantable ports and catheters and certain dialysis catheters. Temporary central lines, on the other hand, are not tunneled. Umbilical catheters are central lines inserted into the umbilical vein or artery in a neonate. There is no minimum time required for a central line to be in place for a bloodstream infection to be considered central line associated (Centers for Disease Control and Prevention, 2016).

Significance and Impact

An estimated 30,100 Central Line-Associated Bloodstream Infections (CLABSIs) occur in U.S. hospital wards and intensive care units each year. A higher estimate places the number of infections at 82,000 and the number of related deaths at 28,000 (Klevens, et al., 2007). The difference in these figures in however accounted for as the CDC reports that between 2008 and 2016, there has been a 46% reduction in CLABSIs (Centers for Disease Control and Prevention, 2016). CLABSIs are severe infections and often cause increased risk and costs of mortality as well as prolonged hospital stay. CLABSIs pose a significant problem in health care since conservative assumptions associate each CLABSI with a mortality of up to 25% and excess healthcare costs of $16500. Therefore, assuming that 30,100 CLABSIs occur in one year, there will be 7525 deaths associated with CLABSIs and $496,650,000 worth of excess healthcare costs.

Therefore, even to the organization or healthcare provider itself, CLABSIs have a large impact, not only in term of the excess financial costs but also because of the mortality and associated decline in health quality and reputational reviews. A health care facility with a high rate of CLABSIs will be ranked lower in terms of quality of care and adherence to evidence-based standards.[G1] [G2] 

Risk Factors

There are a number of risk factors associated with acquiring a CLABSI. These factors can either be intrinsic, which refers to non-changeable traits that the patients have, or extrinsic, which are modifiable factors associated with Central Venous Catheter (CVC) insertion or maintenance, or the environment within which the patient is receiving care. The characteristics of the CVC as well as its insertion and post-insertion maintenance have the largest impact on the overall risk of CLABSI (Niedner, 2010). Intrinsic factors include:

• Patient’s age – children are more prone to CLASBIs than adults (Dudeck, et al., 2011)
• Underlying conditions or diseases – cardiovascular disease, immunological and hematological deficiencies, and gastrointestinal disease have been linked with an elevated risk for CLABSIs (Mollee, et al., 2011; Wylie, et al., 2010)
• Gender – males are at a heightened risk for CLABSIs (Advani, Reich, Sengupta, Gosey, & Milstone, 2011)

Extrinsic risk factors include:

• Prolonged hospitalization before CVC insertion
• Multiple CVCs (Kritchevsky, et al., 2008)
• Parenteral nutritional administration (Advani, Reich, Sengupta, Gosey, & Milstone, 2011; Kritchevsky, et al., 2008)
• CVC insertion (Kritchevsky, et al., 2008; Wylie, et al., 2010)

This paper shall focus on CVC insertion preparation an insertion techniques as the current practice highly related to the CLABSI rate problem. It has been shown that CVCs can be contaminated with microorganisms through two major routes:

1. Extraluminally – whereby the microorganisms on the patient’s skin at the insertion site migrate along the catheter’s surface into the cutaneous catheter tract surrounding the catheter (Chopra, O’Horo, Rogers, Maki, & Safdar, 2013).
2. Intraluminally – The most common way for this to occur is when the IV system is manipulated, for example, when health care personnel have had hand contact with access hubs, IV solution connection sites, tubing junctions, or needleless connectors, or contamination with the patient’sown skin or body fluids. 

These contamination mechanisms are all related to the manner in which health care personnel both prepare for CVC insertion, and the way in which they carry out the actual insertion. The recommendation that will be given in this paper will attempt to reduce the rate of CLABSIs by addressing CVC insertion preparation and techniques.[G3] [G4] [G5] [G6] 

                                                                 Search Strategy                 

Keywords

There are a number of keywords that I used when searching for appropriate literature relevant to this paper. The first and primary keywords that I used were “Central line-associated bloodstream infections”. This keyword was used in over 90% of the searches that I did when looking for relevant literature. I combined these keywords with others listed below to get more specific results: definition; mortality rates; annual infections; risk factors; and, evidence-based prevention.

Types of Articles Encountered

 A general search on the Google search engine of the primary keyword yielded 473,000 results. There were a wide variety of articles yielded. Some of these articles were reports prepared by various organizations and agencies such as the CDC, The Joint Commission, and World Health Organization. These reports were quite comprehensive, and depending on their publication date, had quite recent statistics regarding CLABSIs. Other types of articles, and which comprised the greater majority, were articles published on websites. A large number of these articles did not have specific authors and were issued by the entity behind the particular website. Another type of articles available were those published by students presenting papers to fulfill project, thesis, dissertation, or other scholarly requirements. Articles published by scholars in various periodicals such as journals and magazines were also available. [G7] [G8] Within the first page, the search results comprised of 3 reports, 12 articles published on websites, and five scholarly articles posted on various websites.[G9] [G10] [G11] [G12] [G13] [G14] [G15] [G16] 

A search on the Google Scholar search engine yielded more scholarly articles, most of which were akin to the latter mentioned types of articles. The specific number of results given related to the primary keyword was 9,170. However, for a majority of these articles, only the abstract was available for viewing. Within the first page, only 4 out of 10 articles was able for full viewing.

Article Discussion

One research-based evidence source used is titled “The harder you look, the more you find: Catheter-associated bloodstream infection surveillance variability” (Niedner, 2010). The researchers carried out a survey of 5 health care professions at various institutions to assess variability in CLABSI management, surveillance practices, and beliefs/attitudes in pediatric intensive care units. The author found a wide variation in the CLABSI surveillance practices on multiple fronts: from the interpretations of the CDC definition to application of diagnostic strategies. The author believes that although there are common practices applied in CLABSI surveillance and management, it is not evident if these are best practices. [G17] [G18] Furthermore, even though it has been shown that health care worker practices impact CLABSI rates far more than intrinsic risk factors, the author found that the health care workers solicited in the study were not of this perception. The author, therefore, suggests that individual institutions should recalibrate their surveillance practices With regards to the health care staff, their opinions of the most necessary drivers of CLABSI ma be required. The best way of recalibrating such skewed perceptions is through specific education and training, something observed by the authors of t[G19] [G20] [G21] [G22] [G23] [G24] he second research evidence source that was considered. [G25] [G26] [G27] [G28] [G29] 

The second research evidence source article was titled “Effect of education on the rate of and understanding of risk factors for intravascular catheter-related infections” (Yilmaz, Caylan, Aydin, Topbas, & Koksal, 2007). The authors conducted a study at a medical school in Turkey where they found that the CLABSI rate dropped to 4.7 infections per 1,000 catheter-days from 8.3 infections per 1,000 catheter-days. The authors observed that it is essential for health care workers to be informed about the causes of CLABSI and the methods of preventing it. By comparing the knowledge of the staff concerned before and after they received education, the researchers found a significant increase in the health care worker’s knowledge level right after the training. A notable improvement in the rate of CLABSIs was also observed. The results of this study are comparable to other studies that investigated the effect of education on the rate of nosocomial infections (Coopersmth, et al., 2002; Parra, et al., 2010; Warren, et al., 2004) It is, therefore, clear from the above two research evidence sources that education and training is an important tool in the reduction and prevention of CLABSIs. [G30] [G31] [G32] [G33] 

With regards to non-research evidence sources, one that was considered is titled “Preventing Central Line-Associated Bloodstream Infections: A Global Challenge, A Global Perspective” (The Joint Commission, 2012). The Joint Commission produced this monograph to provide information on:

• Types of central venous catheters and pathogenesis and risk factors for CLABSIs
• Position papers, evidence-based guidelines, published literature, and patient safety initiatives on CLABSI and its prevention
• CLABSI prevention technologies, techniques, and strategies, and barrier to best practices

Another non-research evidence source considered is titled “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update” (Marschall, et al., 2014).The authors seek to demonstrate practical recommendations that can be implemented by acute care hospitals in their efforts to prevent CLABSIs. These two non-research based evidence sources highlight some similar methods and strategies used to prevent and reduce CLABSIs. Some of the common ones featured include:

• Pre-insertion preparation – education of health care personnel; and, chlorhexidine use.
• Insertion – aseptic technique; and hygiene; use of an all-inclusive catheter cart; ultrasound guidance; and, maximal sterile barriers.
• Post-insertion – appropriate nurse-to-patient ratio; disinfection of needleless connectors, catheter hubs and injection ports; removal of non-essential catheters; antimicrobial ointments for hemodialysis catheter insertion sites; and, surveillance for CLABSI[G34] 

These sources confirm the earlier conclusion derived from the research evidence sources which alludes to the importance of education in CLABCI prevention. It should be observed that most of the elements included in the above CLABSI prevention strategies list involve [G35] prior[G36]  education and training for the staff so as to familiarize them with the appropriate methodologies.  [G37] [G38] [G39] 

                                                               Recommendation                                  

Education and Training of Health Care Personnel

Any effort aimed at reducing CLABSIs commences with the education and training of competent staff members on the proper management of CVC, from insertion preparation to insertion, maintenance, and post-insertion. In this case, the education and training will be specific to CVC insertion preparation and insertion techniques. It has been demonstrated that even in resource-poor areas, basic education, especially education with feedback of CLABSI rates to employees, will result in lower CLABSI rates (The Joint Commission, 2012). All healthcare personnel involved in the insertion and maintenance of CVCs should be competent and knowledgeable concerning care related to CLABSI prevention (Marsteller, et al., 2012). Despite the fact that heath care personnel must keep up with current technological advances in CLABSI prevention, proper procedures and technique for CLABSI prevention are vital. Staff members familiar and experienced with CVC insertion and maintenance may not be as informed about CLABSI risk factors, or evidence-based practices aimed at preventing them. Staff competence should be evaluated at the time of initial employment, on a regular ongoing basis, when the staff member’s purview of practice changes, and when new equipment or technology is introduced.

There are some key elements that any CLABSI education program should include:

• Suitable indications for CVC insertion – Health care workers should comprehend what comprises reasonable indications for CVC placement, which include: fluid administration; medication administration; providing parenteral nutrition; monitoring of central venous pressure; and, providing hemodialysis.
• Best practices for CVC insertion
• Appropriate maintenance and care measures – Health care staff should comprehend the proper support and care needed to prevent infection after CVC insertion since proper care of the CVC post-insertion is vital to CLABSI prevention

The first two elements in the above list will be crucial for an education and training program targeting CVC insertion preparation and insertion techniques.[G40]  Such an educational program will target specific aspects of CVC insertion preparation and insertion techniques. These aspects include: [G41] [G42] 

CVC Insertion Preparation. Health care personnel should comprehend what constitutes reasonable indication for placement of CVCs, which includes: providing hemodialysis; providing parenteral nutrition; administration of fluids; administration of medications; and monitoring of central venous pressure. Health care personnel should also be attentive to skin preparation, maximal sterile barriers, catheter selection and use of catheter kits.

CVC Insertion Techniques. Staff should be knowledgeable regarding evidence-based practices in CVC insertion. Heath care personnel should also be attentive to catheter site selection, securement devices, insertion under ultrasound guidance, use of a CVC insertion bundle and catheter site dressing regiments.

 Furthermore, the educational methodology selected should consider the principles of adult education, preferred learning methods, cultural norms, resources available, and languages spoken by health care personnel. There are a variety of ways to deliver such education, including:

• ·         Lectures – a study found that a 15-minute talk for ICU medical staff, showing 10 of the evidence-based strategies in the CDC’s guidelines caused a reduction from 4.22 infections from 2.94 infections per 1,000 catheter-days [G43] [G44] [G45]  (Parra, et al., A simple educational intervention to decrease incidence of central line-associated bloodstream infection, 2010)[G46] [G47] [G48] 
• Digital tools such as computerized e-learning or video training (Corner, et al., 2011)
• Self-study modules – These allow health care personnel to red and acclimatize themselves with material at their pace and convenience
• Combining hands-on training with didactic education – Didactic education is useful in knowledge transfer but may not always cause behavior change. Combination with hands-on training ensures that health care personnel have both necessary knowledge and abilities
• Simulation-based training – allows for repetitive, realistic training within controlled environments while avoiding patient harm

Comparison of Other CLABSI Prevention Strategies                                                                 

According to the PICO question, staff education and training on CVC insertion preparation and techniques are compared to other strategies such as hand hygiene, aseptic technique, and CVC management. Hand hygiene is regarded as an essential component of any effective infection prevention and patient safety program. It widely accepted as the single most important measure in preventing infection spread (The Joint Commission, 2012). Proper hand hygiene can be achieved using alcohol-based hand rub products and soap and water. According to the WHO, there are five critical moments for hand hygiene:

• Before touching a patient
• Before aseptic/clean procedure
• After body fluid exposure risk
• After touching patient
• After touching patient surroundings (World Health Organization, 2012)

Aseptic technique refers to a method utilized to prevent microorganism contamination. It applies to all health care settings where surgery or other invasive procedures are carried out. It is used to keep areas and objects free of microorganisms hence mitigating risk for the patient. Evidence-base guidelines recommend aseptic technique for all occasions of CVC insertion and care (Marschall, et al., 2014). CVC management involves all procedures about:

• CVC insertion preparation – maximal sterile barrier precautions; skin preparation; catheter selection; use of catheter carts/kits
• CVC insertion – catheter site selection; insertion under ultrasound guidance; catheter site dressing regimes; securement devices; use of CVC insertion bundle. Use of evidence-based sterile CVC bundles has been shown to be quite useful for CLABSI prevention [G49] [G50] [G51]  (Li & Bizzarro, 2011)[G52] 
• [G53] chlorhexidine bathing; use of CVC maintenance bundle [G54] 
• Catheter or System components removal/replacement – daily review of line necessity; changing administration system components; CVC exchanges over a guidewire

The reason the answer to the PICO question supports the use of staff education and training as opposed to the other methods mentioned above is that all the other methods all entail some aspect of teaching and training. For example, for health care workers to become acquainted with proper hand hygiene, they will have to be informed and educated on the appropriate procedures. The same thing applies to aseptic technique and CVC management, whereby the health care staff will have to undergo some training so as to acquaint and familiarize them with the suitable aseptic technique and CVC management methodologies. Therefore, not only is education and training as effective as these other methods, it is even more efficient as it is an integral part of all the other strategies.

Key Stakeholders for Recommendation Implementation

There are various important stakeholders that should be involved when carrying out a program aimed at preventing CLABSIs. In this case, the program that will be performed entails staff education and training. The primary stakeholder to include within the training program is an [G55] [G56] [G57] infectious disease specialist or a hospital epidemiologist. Microbiologist or Infection Control Nurses may play the role of an Infection Control Specialist. The importance of involving this stakeholder in the decision to implement the education and training program is because this is the Person charged with tracking and recording CLABSIs. They would, therefore, have all the information about the CLABSIs common to that particular health care facility, a vital fact as different CLABSIs may require different approaches to combating them.[G58] [G59] 

Another stakeholder that should be involved in the decision is senior management. At the helm of executives lies the Chief Executive Officer, who is responsible for all that goes on within a health care facility. Accountability commences with such senior leadership as they provide the imperative for CLABSI prevention, thus making CLABSI prevention an organizational priority (Marschall, et al., 2014). Senior leadership is further accountable for dispensing ample resources required for effective implementation of an education-based, CLABSI prevention program. Senior management is further responsible for ascertaining that an appropriate number of health care personnel is assigned to the infection prevention program as well as ample staffing of departments which play and vital role in CLABSI prevention. Senior leadership will also be responsible for holding staff accountable for their actions. For an education program such as this, financial and other resources will be needed, as well as time allocation for conducting the program. These can only be achieved with the aid of senior management, who are not only I direct control of the organization’s finances, but can also influence work schedules to allocate time for training and also provide the necessary room/location for such activities.[G60] 

The other important stakeholders that should be included in the decision comprise of healthcare workers in direct contact with the patient, such as physicians and nurses. These are the stakeholders who deal with the patient directly and thus, form the primary target of the educational program. Since most CLABSIs result from inappropriate CVC management procedures, inclusion of these stakeholders in the decision will ensure that the staff most affected by the training will be part of the program implementation team.

Barriers to Application of Evidence-Based Standards

Numerous barriers to implementation of evidence-based practices to prevent CLABSIs exist within healthcare settings. These obstacles can occur at the organizational, unit and staff levels

Organizational Barriers

• Lack of leadership commitment and support – leadership support of, and involvement in any endeavor to promote organizational change to enhance patient safety cannot be overstated. Such support should start ta the highest level of the organization (Pronovost, et al., 2009)
• ·         Lack of safety culture – a safety-first organizational culture exists when tacit beliefs, behaviors, assumptions, values, and expectations that are widely accepted and shared in an organization support the establishment and maintenance of a safe and healthy work environment for all personnel at all levels [G61] [G62] [G63]  (Goetsch, 2011, p. 694) [G64] [G65] [G66] [G67] 
• Lack of available resources this is a problem mainly associated with middle- and low-income countries and regions. In the first place, adequate supplies of all types may not be available, or may pose a challenge to acquire, such as large sterile drapes and chlorhexidine. Furthermore, resource-poor regions will also experience high incidences of reuse of equipment, such as needles and gloves. Valuable human resources, for example, trained infection preventionists, may also be lacking in such resource-poor regions. Lastly, lack of ongoing surveillance for CLABSIs and other nosocomial infections causes delays in outbreak detection, hence resulting in infection-associated mortality and cost increases.

Unit Barriers

• Nursing staffing variables – This may have an impact on patient safety in the following ways. First of all, nurses have the most ongoing and direct role in patient care of all healthcare personnel. Inadequate nurse staffing has been linked to increased risk of injuries and errors (Stone, Clarke, Cimiotti, & Correa-de-Araujo, 2004). Use of nonpermanent nursing staff has also been associated with significant CLABSI risk.

Staff Barriers

• Experience, training, education, and competence of staff – studies have shown that intensified training and educational programs mitigate the risk of CLABSIs. Inexperienced staff involved in CVC insertion have been linked with lower adherence to CVC insertion guidelines and a higher risk of complications (Kritchevsky, et al., 2008; Yilmaz, Caylan, Aydin, Topbas, & Koksal, 2007)

Strategies for Overcoming Barriers

One of the most important strategies that can be used in overcoming the barriers mentioned above has to do with implementation of educational and training programs. It has clearly been established the critical role that education and training have on the reduction of CLABSIs. Furthermore, insufficient experience, education, and training have been identified as a staff associated barrier to utilization of evidence-based CLABSI prevention methods. Therefore, this strategy aligns with the recommended practice change mentioned above that is entirely pegged on educational and training programs aimed at CLABSI prevention and mitigation. The educational programs should address critical thinking, knowledge, psychomotor and behavior skills and beliefs and attitudes. Furthermore, since adult learners use multiple ways to learn, various teaching strategies should be employed. These include instructor-led courses, self-directed study guides, digital learning methods, and group discussions. The planning for the [G68] educational offering should involve representatives from multiple professions, including nurses, physicians, and infection preventionists. [G69] 

Another important strategy that can address the barriers mentioned above entails leadership engagement. Organizational leadership is vital to any safety and health program, and therefore, they must be engaged in the process for it to be successful. Therefore, this strategy involves getting the support of top leadership regarding safety and health issues within the health care facility. The best way to do this would be to start from the very top, the CEO, since this is the one person who has the power to influence all his subordinates, including fellow senior management. Senior management should not only be encouraged to endorse various CLABSI prevention efforts but also to promote such efforts actively and facilitate smooth implementation of any associated program.[G70] [G71] 

Indicator Measure for Recommendation

 One indicator that can be used to measure the outcome related to the education and training proposal is the number of infections per 1,000 catheter days. This is a standard test that will clearly demonstrate the effectiveness of the recommendation by measuring the number of CLABSI infections that occur.

                                                                     Conclusion                                                                     CLABSIs pose a significant threat to modern healthcare and even though significant steps have been taken to slash the rate of such infections within the past decade, the rate of CLABSIs remains high as do the associated mortality rates and excess healthcare costs. Quality improvement interventions have been shown to significantly decrease the rate of CLABSIs (Blot, Bergs, Vogelaers, Blot, & Vandijck, 2014; Wheeler, et al., 2011). One of the best strategies used to achieve such improvement in quality, and that can be implemented to prevent CLABSIs

involves education and training of health care personnel.

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Parra, A. P., Menarguez, M. C., Granda, M. J., Tomey, M. J., Padilla, B., & Bouza, E. (2010). A simple educational intervention to decrease incidence of central line-associated bloodstream infection. Infection Control & Hospital Epidemiology, 31(09), 964-967. Retrieved from https://www.researchgate.net/profile/Maria_Granda2/publication/45364568_A_Simple_Educational_Intervention_to_Decrease_Incidence_of_Central_Line-Associated_Bloodstream_Infection_(CLABSI)_in_Intensive_Care_Units_with_Low_Baseline_Incidence_of_CLABSI/links/5

Parra, A. P., Menarguez, M. C., Granda, M. J., Tomey, M. J., Padilla, B., & Bouza, E. (2010). A simple educational intervention to decrease incidence of central line–associated bloodstream infection (CLABSI) in intensive care units with low baseline incidence of CLABSI. Infection Control & Hosital Epidemiology, 31(9), 964-967.

Pronovost, P. J., Goeschel, C. A., Marsteller, J. A., Sexton, J. B., Pham, J. C., & Berenholtz, S. M. (2009). Framework for patient safety reserach and improvement. Circulation, 119(2), 330-337. Retrieved from http://circ.ahajournals.org/content/119/2/330.full

Stone, P. W., Clarke, S. P., Cimiotti, J., & Correa-de-Araujo, R. (2004). Nurses’ workign conditions: implications for infectious disease. Emerging Infectious Diseases, 10(11), 1984-1989. Retrieved from http://www.heart-intl.net/HEART/050107/NursesWorkingConditions.htm

The Joint Commission. (2012). Preventing Central Line-Associated Bloodstream Infections: A Global Challenge, A Global Perspective. Oak Brook: Joint Commission Resources. Retrieved from https://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf

Warren, D. k., Zack, J. E., Mayfield, J. L., Chen, A., Prentice, D., Fraser, V. J., & Kollef, M. H. (2004). The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU. CHEST Journal, 126(5), 1612-1618.

Wheeler, D. S., Giaccone, M. J., Htchinson, N., Haygood, M., Bondurant, P., Demel, K., . . . Rich, K. (2011). A hospital-wide quality-improvement collaborative to reduce catheter-associated bloodstream infections. Pediatrics, 128(4), e995-e1007.

World Health Organization. (2012). WHO Guidelines on Hand Hygiene in Health Care. Geneva: WHO. Retrieved from http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf

Wylie, M. C., Graham, D. A., Potter-Bynoe, G., Kleinman, M. E., Randolph, A. G., Costello, J. M., & Sandora, T. J. (2010). Risk factors fo central line-associated bloodstrea infection in pediatric intensive care units. Infection Control & Hospital Epidemiology, 31(10), 1049-1056. Retrieved from https://www.researchgate.net/profile/Monica_Kleinman2/publication/45819724_Risk_Factors_for_Central_Line-Associated_Bloodstream_Infection_in_Pediatric_Intensive_Care_Units/links/00b7d5379f518c1bf0000000.pdf

Yilmaz, G., Caylan, R., Aydin, K., Topbas, M., & Koksal, I. (2007). Effect of education on the rate of and understanding of risk factors for intravascular catheter-related infections. Inection Control and Hospital Epidemiology, 28(6), 689-694. Retrieved from https://www.researchgate.net/profile/Iftihar_Koeksal/publication/6311372_Effect_of_Education_on_the_Rate_of_and_the_Understanding_of_Risk_Factors_for_Intravascular_CatheterRelated_Infections_/links/54fb4cd90cf2c3f52420477d.pd

PICO Table