1. PICO Presentation Decreasing Infection Rates in Central Lines
Carrie Hallihan, RN
4/22/2016
COHP 450
Ferris State University
RN to BSN

2. Introduction & Purpose
Central line use in health care is pretty common these days due to easy access, less invasive for patients, and more convenient for treatments that help with cancer, nutrition, or fighting infections.
In my place of work on the med-surg floor, I see central lines frequently and I’ve always wondered about the best way to prevent infections when one of my patients has one. This presentation will investigate central lines and their infection rates when two different techniques are used.
A relevant PICO question has been formed and we’ll investigate two related studies regarding this topic.
“Generally, healthcare professionals investigate problems that interest them or impact their work and clinical care. Therefore, any question in practice, specialty, or interest is worth researching” (Forister & Blessing, 2016)

3. The PICO Question
In hospitalized patients that have central line access, does the use of alcohol-impregnated port protectors have a lower infection rate compared to those patients that do not have the alcohol-impregnated port protectors?
Patient/Population - hospitalized patients
Intervention - use of alcohol-impregnated port protectors
Comparison - patients who do not have alcohol-impregnated port protectors
Outcome - lowered infection rate with use of alcohol-impregnated port protectors

4. Literature Results
The two research studies I used to support my PICO were found from two sites within Ferris State University’s FLITE library database:
CINAHL
Pub Med
I used a variety of search words to help find supporting data:
Port protector, protective cap, central line infection, and catheter associated infections
After narrowing down the search fields to exactly what I was looking for, there were at least 43 results from CINAHL alone.
“CINAHL is a database that covers content in the subject areas of nursing and allied health. Many academic libraries, hospitals, and even some public libraries purchase access to CINAHL” (Forister & Blessing, 2016).
“MEDLINE, which is produced by the National Library of Medicine, is free to all as part of the content of a user-friendly interface called PubMed” (Forister & Blessings, 2016).
Forister, J.G. & Blessing, J.D. (2016). Introduction to Research and Medical Literature for Health Professionals. (4th Edition). Burlington, MA. Jones & Bartlett. p. 35, 36

5. PICO Research Articles
Study 1
Sweet, M.A., Cumpston, A., Briggs, F., Craig, M., Hamadani, M. (2012). Impact of
alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit. American Journal of Infection Control, 40(10), doi: /j.ajic
Study 2
Ramirez, C., Lee, A.M., Welch, K. (2012). Central Venous Catheter Protective Connector
Caps Reduce Intraluminal Catheter-Related Infection. Journal of the Association for
Vascular Access, 17(4), doi: /j.java

6. Article Relevance
Central line infections and how to decrease the occurrence was the main focus for both articles.
Use of alcohol-impregnated port protectors were used in both research articles compared to current practice of “cleaning the hub with an alcohol sponge for 15 seconds” (Ramirez, Lee, Welch, 2012).
Both research articles had a total of 1 central line-associated blood stream infection (CLABSI) at the end of their studies.
CLABSI occurrence in the hospital setting of both studies decreased with the implementation of alcohol-impregnated port protectors.
Found to be scholarly and peer-reviewed
Current research (both articles 2012)
Ramirez, C., Lee, A.M., Welch, K. (2012). Central Venous Catheter Protective Connector Caps Reduce Intraluminal Catheter-Related Infection. Journal of the Association for
Vascular Access, 17(4), 211. doi: /j.java

7. Type of Study, Design, & Methods
Research Study 1
Research Study 2
Nonrandomized prospective trial, implemented in 2 intensive care units
Observational before-after trial in tertiary care hospital oncology unit
Study occurred
March 1, 2011 – February 2012
January 1, 2010 – July 1, 2010
All patients in our ICU with an indwelling central line who were receiving IV treatments through the line.
Adult patients with a central venous catheter
Quantitative Research
Statistical Analysis of Data: Continuous
To evaluate CLABSI, data was collected on number of central line-days and number of patients with CVC, just to name a few.
To evaluate CLABSI, data was collected on number of patients with CVC, number of patient-days, and number of CVC-days (number per patient per day)
Research Study 1:
“The decision to include all patients was made because the facility had reliable data on CLABSI-related infections for the previous 3 years and because introducing the cap was the only change made to the process of inserting and caring for the lines. No randomization was attempted, the premise being that during the study period the patient mix would be comparable with the patient mix seen during the 3 previous years” (Ramirez, Lee, Welch, 2012).
Research Study 2:
“The intervention period (January-July 201) was compared with historical control (January-December 2009)” (Sweet, Cumpston, Briggs, Craig, Hamadani, 2012).

8. Study Findings
Research Study 1
Research Study 2
For the period of March 1, 2011 – February 2012, there was 1 central line-associated blood stream infection (CLABSI).
For the period of January – July 2010, 3,005 central line-days resulted in 1 central line-associated blood stream infection (CLABSI).
* 282 patients with CVC accounting for a total of 479 hospital admissions
Compared to:
In 2010, there were 4 CLABSIs.
Control period of January-December 2009, had 6,851 central line-days and resulted in 16 CLABSIs.
* 472 patients with CVCs accounting for total of 911 hospital admissions
Study 1:
“Our one year trial resulted in a significant decrease in CLABSIs. The goal of our trial was to find out if maintaining sterility at the port site using an alcohol-impregnated cap would have an affect on catheter-associated blood stream infections in our ICU. Our results indicate that consistent use of caps in tandem with utilization compliance does influence CLABSI rates” (Ramirez, Lee, Welch, 2012).
Ramirez, C., Lee, A.M., Welch, K. (2012). Central Venous Catheter Protective Connector Caps Reduce Intraluminal Catheter-Related Infection. Journal of the Association for Vascular Access, 17(4), doi: /j.java
Study 2:
“The primary outcome of this study was the reduction of CLABSIs after the implementation of a quality improvement measure. The primary goals of our intervention were to decrease CLABSIs” (Sweet, Cumpston, Briggs, Craig, Hamadani, 2012).
Sweet, M.A., Cumpston, A., Briggs, F., Craig, M., Hamadani, M. (2012). Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit. American Journal of Infection Control, 40(10), doi: /j.ajic

9. Ethical Consideration
Each study had statistics that warranted a concern for increased infections with CVCs. They showed support towards completing this study to help benefit the patients in health care setting.
Both studies were approved by the Institutional Review Board.
“IRBs are committees that consist of 5 or more members with varying expertise and diversity that are responsible for reviewing and approving human subjects research activities on behalf of institutions” (Protecting Human Research Participants, 2011, pg. 33)
The intervention that was done in both studies was minimally invasive to patients (adding alcohol-impregnated protector caps)
“Two general rules have been articulated as complementary expressions of beneficent actions: do no harm and maximize possible benefits and minimize possible harms” (Protecting Human Research Participants, 2011, pg 63).
Both studies took into account the patients involved, risks, harms, and overall benefits when completing these studies. I also believe that both studies took into account the Belmont Principles. “Respect for persons where they treat individuals as autonomous agents capable of making informed choices and acting on them. Beneficence where they maximize possible benefits and minimize possible harms. Justice where fairness in distribution of the benefits and burdens occur” (Forister & Blessing, 2016).
“These three basic principles serve as the foundation of the current HHS regulations and guidelines for the ethical conduct of human subjects research supported by HHS” (Protecting Human Research Participants, 2011, pg 17).
Study 1:
“Central line-associated blood stream infection (CLABSI) rates in adult care intensive care units have been decreasing across the board. However, we continue to see a few infections in patients whose catheters are in for >4 days. Therefore, we looked at infections associated with intraluminal contamination to help reduce our infection rate” (Ramirez, Lee, Welch, 2012).
Study 2:
“A major risk factor for the development of bloodstream infection is the presence of a central venous catheter (CVC). CVC hub contamination is a risk factor for central line-associated bloodstream infection (CLABSI)” (Sweet, Cumpston, Briggs, Craig, Hamadani, 2012).
Privacy and confidentiality

10. Study Strength, Quality, & Credibility
Research Study 1
Research Study 2
Peer reviewed medical journal
* Journal of the Association for Vascular Access
*American Journal of Infection Control
“Trial design and implementation developed through the critical care service line. Multidisciplinary meetings were conducted emphasizing education on trial design and implementation”
(Ramirez, Lee, Welch, 2012)
Writers of article have extensive credentials:
Pharm D, MPH, MD
MD, MPH, MEd, RN
References from study are creditable
“This quality improvement measure was a single-center analysis in the hematology/oncology unit at West Virginia University Hospitals. The study was approved by the Institutional Review Board” (Sweet, Cumpston, Briggs, Hamadani, 2012).
Study 1: Ramirez, C., Lee, A.M., Welch, K. (2012). Central Venous Catheter Protective Connector Caps Reduce Intraluminal Catheter-Related Infection. Journal of the Association for
Vascular Access, 17(4), doi: /j.java
Study 2: Sweet, M.A., Cumpston, A., Briggs, F., Craig, M., Hamadani, M. (2012). Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit. American Journal of Infection Control, 40(10), doi: /j.ajic

11. Evidence-Based Practice
“In 2009, central line-associated bloodstream infections (CLABSIs) accounted for 23,000 infections in inpatient units and 18,000 infections in intensive care units in US hospitals. A major risk factor for the development of a bloodstream infection is the presence of a central venous catheter” (Sweet, Cumpston, Briggs, Hamadani, 2012).
“Studies of current IV practices demonstrated that 56% of registered nurses typically do not believe it is necessary to disinfect catheter hubs” (Ramirez, Lee, Welch, 2012)
Research Study 1 criteria included looking at infection rates of patients who had CVCs over a specific time frame. They also looked at compliance of using the port protectors.
Research Study 2 criteria included looking at infection rates of patients who had CVCs over a specific time frame. Patient characteristics were looked at as well as what kind of infections grew.
There is clearly a valid reason to complete this type of study on this given PICO question due to increased risk of infection to patient based on how the facility cares for CVC.
If the new intervention works to decrease infection rates (providing cap protectors) and there is no harm to patients in doing so, why not continue to implement such measures going forward in the health care setting? This result from both studies helps to support the intervention towards Evidence Based Practice.
With simple implementation of the alcohol impregnated protector caps, risk for infection decreased across the board with patients who had CVCs.
Study 1: Ramirez, C., Lee, A.M., Welch, K. (2012). Central Venous Catheter Protective Connector Caps Reduce Intraluminal Catheter-Related Infection. Journal of the Association for
Vascular Access, 17(4), doi: /j.java
Study 2: Sweet, M.A., Cumpston, A., Briggs, F., Craig, M., Hamadani, M. (2012). Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit. American Journal of Infection Control, 40(10), doi: /j.ajic

12. Relevance to my Practice?
The findings from both studies are very significant to the health care field, especially patients who have central venous catheters. No patient wants to develop an infection while in the hospital. These two studies support proper practice of caring for central venous catheters.
The findings would be communicated:
Via medical / healthcare journals
Any floor that utilizes central lines (my place of work is med-surg and we do see central lines)
Management would share information at department/staff meetings
Trainings for RNs on proper protocol for taking care of central lines with implementation of alcohol impregnated port protectors so everyone is compliant and educated
New policy written on taking care of central lines with addition of port protectors, which is supported by evidence based practice
Originally, our current process on the med-surg floor was to just use alcohol swabs on the hubs of the central line for 15 seconds.

13. Implications for Change in Practice
These two studies show great evidence towards a need to change the way central venous lines are cared for. There is clearly a concern for patients who have central venous lines. There is a better way to care for these lines that will decrease infection rates in patients. Statistics show increased risk for infection with any patient who has a central venous line.
These studies I believe would fall under applied research because the results can clearly be used or applied to improve patient care. It’s a simple intervention that is proven to reduce rates of CLABSIs.
Implementation of alcohol-impregnated port protectors:
Decreases risk of infection rates
Ease of use
Improves safety and quality of care in patients
Implementation of procedure change would be at the RN level; who tend to the central venous lines daily. But this change would also occur within written procedure policies and standards of care.
My PICO question was formulated based upon what I saw on the med-surg floor of my current work place. Many patients are admitted with central venous lines and caring for those lines takes on additional tasks. But also, with patients who have those type of lines, the risk for infection is greater. I definitely would say that these two research studies would be considered applied research supporting my PICO question. “Applied research is designed to answer a practical question, to help people do their jobs better. Examples include evaluation of different types of interventions with the same purpose” (Forister & Blessing, 2016). I think because these two research studies are applied research, it strengthens each study because there is clearly a purpose. These studies can be used to encourage positive change in procedures around caring for central venous lines.
Both studies I believe would be quantitative in nature so therefore, these studies are considered “systematic, objective, include large sample sizes, involve numbers, and are generalisable” (Nursing Research/Theory, 2015).
Nursing Research/Theory – Quantitative vs Qualitative. (2015). The University of Texas at Austin School of Nursing. Retrieved from

14. Potential Barriers
Non-compliance of RN staff following new procedure of implementing alcohol-impregnated port protectors across the board.
Cap availability at the bedside
Education provided to RNs on procedure changes
Treatment vs. prevention
“The main barrier identified by users was related to cap availability at the bedside. A decision was made to add cap strips that could be hung on IV poles in patient rooms” (Ramirez, Lee, Welch, 2012).
“The paradigm for dealing with health care-associated infections needs to shift from treatment to prevention. Strategies to prevent CLABSIs can be categorized into 3 areas of practice: before central line insertion, at the time of insertion, and after insertion” (Sweet, Cumpston, Briggs, Craig, Hamadani, 2012).
Study 1: Ramirez, C., Lee, A.M., Welch, K. (2012). Central Venous Catheter Protective Connector Caps Reduce Intraluminal Catheter-Related Infection. Journal of the Association for
Vascular Access, 17(4), doi: /j.java
Study 2: Sweet, M.A., Cumpston, A., Briggs, F., Craig, M., Hamadani, M. (2012). Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit. American Journal of Infection Control, 40(10), doi: /j.ajic

15. Additional PICO Questions?
In hospitalized patients that have central line access, does having a dedicated team to oversee all central lines in the hospital decrease the infection rate compared to having bedside nurses be responsible for the maintenance of the lines?
In hospitalized patients that have central line access, does changing the alcohol impregnated port protectors more frequently decrease the infection rate compared to not changing them at all?
In hospitalized patients that have central line access, does having RNs attend education classes on proper technique of caring for central lines decrease the infection rate compared to not attending any education classes at all?

16. Conclusion
The PICO question is very important to patients, medical staff, and to the outcome of the patient’s wellbeing.
The research study articles discussed here correlate with the PICO question that has been presented in the health care setting.
Both studies clearly support the benefit of using alcohol impregnated port protectors to decrease infections seen in patients with CVCs.
Bottom line is that the intervention suggested in the PICO question benefits patients by decreasing their risk of infection or additional complications when they have CVCs.
Implementation of using the alcohol impregnated port protectors is NOT the only step in decreasing infections with CVCs. Other steps must also be taken:
Compliance with all nursing staff to use them
Proper technique when handling CVCs
Cap availability at the bedside
Proper education provided to all staff

17. References
Forister, J.G. & Blessing, J.D. (2016). Introduction to Research and Medical Literature for Health Professionals. (4th Edition). Burlington, MA. Jones & Bartlett. p. 6, 12, 24, 35, 36
Nursing Research/Theory – Quantitative vs Qualitative. (2015). The University of Texas at Austin School of Nursing. Retrieved from
Protecting Human Research Participants. (2011). National Institute of Health – Office of Extramural Research. Retrieved from
Ramirez, C., Lee, A.M., Welch, K. (2012). Central Venous Catheter Protective Connector Caps Reduce Intraluminal Catheter-Related Infection. Journal of the Association for Vascular Access, 17(4), doi: /j.java
Sweet, M.A., Cumpston, A., Briggs, F., Craig, M., Hamadani, M. (2012). Impact of
alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit. American Journal of Infection Control, 40(10), doi: /j.ajic