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University of Texas at Tyler
Scholar Works at UT Tyler
MSN Capstone Projects School of Nursing
Spring 4-17-2022
Central Line Maintenance Team
Lauren Spears
lspears@patriots.uttyler.edu
Follow this and additional works at: https://scholarworks.uttyler.edu/nursing_msn
Part of the Nursing Commons
Recommended Citation
Spears, Lauren, "Central Line Maintenance Team" (2022). MSN Capstone Projects. Paper 188.
http://hdl.handle.net/10950/3960
This MSN Capstone Project is brought to you for free and open access by the School of Nursing at Scholar Works
at UT Tyler. It has been accepted for inclusion in MSN Capstone Projects by an authorized administrator of Scholar
Works at UT Tyler. For more information, please contact tgullings@uttyler.edu.Central Line Maintenance Team 1
Impact of a Central Line Maintenance Team on CLASBIs
A Paper Submitted in Partial Fulfillment of the Requirements
For NURS 5382: Capstone
In the School of Nursing
The University of Texas at Tyler
by
Lauren N. Spears
April 17th, 2022Central Line Maintenance Team 2 Contents Acknowledgements Executive Summary Implementation and Benchmark Project 1. Rationale for the Project 2. Literature Synthesis 3. Project Stakeholders 4. Implementation Plan 5. Timetable/Flowchart 6. Data Collection Methods 7. Cost/Benefit Discussion 8. Discussion of Results Conclusions/Recommendations References Appendix
Central Line Maintenance Team 3
Acknowledgments
I would like to acknowledge my parents and sister who were a listening ear for all my
venting sessions throughout the past two years. Thank you to family and friends who kept me
encouraged along the way.
Thank you to the staff at UT Tyler during my clinical time there. Thank you, Natalie
Serrano, my preceptor, for being a listening ear and for all the advice you gave to help me be a
successful educator in the future. Thank you, Ann Campbell, for the advice you gave as an
educator and researcher. Thank you, Sandy Savage, for being the burst of energy and motivation
I needed. Thank you, Rebecca Williams, for giving me the pep talk I needed to enroll into my
Masters Program.
To the graduate staff, Dr. Belinda Deal, Dr. Mona Gaw, and Dr. Colleen Marzilli, thank
you for all your help and guidance during the research process. With your help and guidance, I
will be able be an even better nurse, because I will be able to lead evidence-based practices.
Thank you, Janet Rainey (Graduate Advisor), for keeping me on track to graduate in 2 years.Central Line Maintenance Team 4
Executive Summary
January 2019, a presenter for a new hire hospital orientation stated “the reason the hospital
remains so successful is because we are dedicated to innovation and evidence-based practice”. One may
be confused on how the two relate, but both are a necessity to keep a hospital marketable. Evidence-based
should not be seen as a process, but as a dynamic because it suggests a high level of fluidity, mobility,
and portability (Melynk & Overholt, 2019).
Central line associated blood infections (CLASBIs) are identified as a hospital acquired infection
(HAI) (Centers For Disease Control and Prevention, 2019). Meaning that the hospital is found liable and
financially responsible for any hospital acquired infection and will not receive any Medicare/Medicaid
reimbursement. The average cost of a CLASBI per case is $48,108 (Agency for Healthcare Research and
Quality, 2017).
Centers for Medicare and Medicaid Services (CMS) is the largest payer of healthcare services
(Centers for Medicare & Medicaid Services, 2021). CMS encourages quality improvement by paying
incentives if the hospital does well with quality initiatives. However, they will also reduce or withhold
payments if quality measures are not met. Monetary loss for the hospital is determined by Centers for
Medicare and Medicaid Services (CMS) using the Hospital Acquired Condition Reduction Program
(HAC). Annually, CMS reviews the hospital’s HAC score. If the HAC score is greater than the 75th
percentile, the hospital receives a one percent payment reduction (Centers for Medicare & Medicaid
Services, 2021). Hospitals rely heavily on CMS funding to pay staff, get needed equipment, and provide
quality care to patients.
65-70% of CLASBIs are preventable (Karapanou et al., 2019). With dedication to implementing
evidence-based practice, CLASBI rates will decrease, and hospitals will not lose funding. This process in
beneficial to management, staff, and patients.Central Line Maintenance Team 5
Central Line Maintenance Team
Central lines are common within the Intensive Care Unit and are needed due to the administration
of high dose antibiotics, total parenteral nutrition (TPN), and pressors. However, patients are at risk for
developing central line associated bloodstream infections that can prolong their hospital stay. Decreasing
CLASBI infection rates to zero requires a team approach. A central line maintenance team has been
suggested to help implement central line bundles. The bundle includes daily assessments for if the central
line is still needed, assessment of the central line dressing, impregnated CHG dressings, and observation
of hand hygiene technique.
The following PICOT question was formed to help with the research on this topic: Among
critically ill patients (P), how does implementing a central line maintenance team (I) compared to current
practice of clinical nurses being responsible for central line maintenance (C) decrease CLASBI rates (O)
while central lines are in place (T)?
Rationale for the Project
CLASBIs can be detrimental to the patient population. Patients and family members are already
under a great deal of stress, emotionally and financially, when a patient is hospitalized. A patient
developing a CLASBI can lead to increased hospitalization stay and even death. Between 250,000-
500,000 CLASBI rates are estimated yearly with a 10-30% chance of mortality (Perin at al., 2016).
Studies have shown that line teams can reduce CLASBI rates by 65% which is very beneficial
for the patient population (Cuccaro et al., 2020).
The maintenance team also gives a support for the bedside nurse who can be
overwhelmed due to the acuity of their patients (Stroever et al., 2019). The heavy load of tasks
required for ICU patients can cause stress and affect quality of care (Aloush, S. d& Alsaraireh,
2018). Implementation of this team can also boost morale on intensive care units.Central Line Maintenance Team 6
Goals
The goal of this project is to improve patient outcomes by providing evidence-based
interventions. For patients to have better outcomes, bedside nurses need the support to achieve those
outcomes. The goal is for the bedside nurse to not feel like they have “one more task” on their already
extensive list of things to accomplish in their shift. Improved patient outcomes help keep the hospital
marketable and competitive and increased morale amongst staff helps with staff retention.
Literature Synthesis.
CLASBIs are defined as bloodstream infections that has an onset of 48 hours after central
line insertion (Foka et al., 2021). To decrease CLASBI rates, central line maintenance bundles
have been implemented over the years to help with prevention of CLASBI rates based on
evidence-based practice. Central line maintenance bundle checklist includes proper hand
hygiene, sterile dressing changes weekly and as needed, checklists and rounding by
management, chlorohexidine baths, and prompt removals of central lines when no longer needed.
Stroever et al. (2020) also suggests two nurses, participating in the changing of a central line
dressing doing sterile technique to help prevent contamination and accidental dislodgments of
the central line.
However, CLASBI rates remain as issue within intensive care units and has proven that
simply implementing a checklist and rounding is not enough (Cavalcanti, A., 2016) (Ista et al.,
2016). Issues of low staff awareness, failure to change institutional practice, and lack of
resources are contributing factors (Foka et al., 2021).
Nurse-led teams that help have been studied to help decrease CLASBI rates (Legemaat et
al., 2015). Legematt et al. (2015), conducted a systemic review that studied the effects of a
vascular access team in a neonatal intensive care unit. The vascular access team was a team ofCentral Line Maintenance Team 7
nurses that had the responsibility of rounding, assisting with central line insertions, changing
central line dressings, and assessing for early removal of central lines. The nurse led team also
changed the practices and policies on the unit to coincide with evidence-based practice. A
decline of CLASBI rates were noted and morale on the unit improved.
The central line maintenance team will be responsible for helping with dressings changes,
assessing central line dressings and sites daily, and helping assess for early removal. The
maintenance team will also be responsible for ensuring current evidence-based practices are
being implemented: ensuring that daily chest x-rays are ordered to verify central line placement,
avoiding femoral sites for central line placement, being sure that sterile field was not broken
during insertion, daily chlorohexidine baths, utilizing chlorohexidine impregnated dressings, and
utilizing Curos disinfecting caps to protect the hub of the central line and IV tubing (Bell, T. &
O’Grady, N., 2017). Education will also be an important responsibility for the maintenance team.
Foka et al. (2020) study showed simulation-based activities, online training, and eLearning
modules for physicians and nurses help with the decline of CLASBI rates.
So, now the question is, what is a better alternative once the central line is determined to
not be needed, but the patient has poor vascular access. PICC line insertions have be proven to
have the least complications when placed by a dedicated PICC insertion team (Silva et al., 2020).
PICC lines can be used for antibiotic therapy and other therapies for four weeks or longer when
maintained properly (Silva et al., 2020).
Project Stakeholders
Project stakeholders for this project include patients and their family members, nurses,
and management. Patients and family members benefit from implementation of this project
because an EBP environment promotes excellence in clinical care that results in improvement ofCentral Line Maintenance Team 8
patient outcomes (Melynk & Overholt, 2019). Patients also influence hospitals' competitiveness
based on reviews and surveys. Nurses benefit as stakeholders from this project because nurses
understand how stressful a shift can be when having to accomplish so many tasks for more than
one patient. This project has the potential to boost morale in intensive care units because nurses
will feel supported. Hospital management are important stakeholders as well because their
support is needed to ensure successfulness with implementation, dissemination, and
sustainability to be successful.
Implementation Plan
It will be asked that unit managers, educators, and charge nurses will help with the daily task
and ensure compliance. The team should spend about 1-2 hours per day to assess sites, help with
as needed dressing changes, and ensure daily x-rays are done. The central line maintenance team
needs to be available on the days of central line dressing changes. After the project is approved
by management and the team is formed and has received education of their roles, the
implementation process will be as followed:
• Step 1: Week 1 and 2, the team will be meet, goals will be discussed, and plan will be formed.
Current policies and procedures should be discussed. Also, current CLASBI rates should be
trended. Dissemination to staff should start within this two week span as well.
• Step 2: Week 3 will be spent introducing the new process to the staff. This will give them the
opportunity to review the new procedure and answer any questions.
• Step 3: Week 4 and 5 will be spent ensuring staff understands the new process. Monitoring the
staff and central line maintenance team compliance to the new procedure should be monitored
throughout all steps. However, this can give a chance to correct any issues regarding non-
compliance.Central Line Maintenance Team 9
• Step 4: Week 6-11 will be spent with ongoing evaluation of the central line maintenance team and
assessing how bedside nurses feel about the new process.
• Step 5: Week 12 will be spent collecting data, creating a trend chart, and presenting to the staff
and management the new data trends.
Timetable/Flowchart
Fall semester of 2020, steps 0-3 of the EBP process were done. The PICOT question was
developed and multiple searches on the University of Texas-Tyler database were conducted to
find three articles. General appraisals (GAO) and rapid critical appraisals (RCAs) were
completed for each article. This happened over a span of three months.
Spring semester of 2021, steps 2-3 of the EBP process were done. Another database
search was completed to find three more articles. GAOs and RCAs were completed on those
three articles. An evaluation table and synthesis table was formed for the current 6 articles. This
process took three months as well.
Fall semester of 2021, step 4 of the EBP process was conducted. Working closely with
Dr. Gaw, the PICOT question reformatted. Integration of the best evidence was done by
completing an EBP change paper to defend the need for change.
Spring semester of 2022, six more articles were searched via the database. GAOs and
RCAs were completed for the six new articles and added to the evaluation table. During the
second half of the semester, step 6 of the EBP process (dissemination) was completed. In total,
the process took a year to complete.
Data Collection Methods
At the start of implementation, current CLASBI rates and practices should be trended.
For data collection methods, all central line insertions during the implementation phase should be
documented and trended. Documentation should include when and why the central line wasCentral Line Maintenance Team 10
placed, the insertion site, and if sterile field was maintained during the insertion (See Appendix
C). This paper should be placed in the patient’s room who has a central line during the
implementation phase. Each day the central line site should assessed for any signs of infection,
documentation of why central line was not removed should be noted, and if central line
maintenance bundle is being complied with. When central line is removed, documentation of if
the central line was cultured should be noted. At the end of the 12-week process, CLASBI rates
should be trended and compared to previous rates to see if improvement of CLABIs have
declined.
Also, a survey amongst the staff can be beneficial. The questions should consist of how
the staff feels about the new process and if improvements need to be made. This helps keep
everyone involved.
Cost/Benefit Discussion
Depending on severity, CLASBIs can cost between $17,898-$94,879 per case (Agency for
Healthcare Research and Quality, 2017). Due to not working for an organization, most costs were
researched via Google. However, companies that sell healthcare supplies will do contracts with
healthcare organizations and bulk orders have the potential to cost less. Chlorohexidine 2% bath
wipes can average about $9.45 per bath (Medline.com). Voor et al. (2017) reports that the
average costs of Curos caps are between $1996-$3556 annually (not inflation-adjusted), but had
a net saving ranged between $39,050-$3,268,990.
Another cost can be staffing. During the implementation phase, it would be asked that
those apart of the team can spend about 1-2 hours per day. If there are concerns of potential
overtime or staffing issues, nurses who work part-time or as needed can be asked to help lead the
team. The central line maintenance team for sure needs to be available on the days of central lineCentral Line Maintenance Team 11
changes, but it should not take 12 hours to accomplish the necessary goals. This cost will be
based on the pay scale at the facility.
Discussion of Results
Due to working at various facilities over the span of the facilities, implementation of the
project was not possible. However, when the project can be implemented, the goal is to decrease
CLASBI rates and improve morale amongst staff. The implementation of a central line
maintenance will be successful. The central line maintenance team will serve as a resource and
expert, but also as an additional advocator for the patients.
Conclusions/Recommendations
When bedside nurses feel that patient care is a team effort, it helps boost morality amongst the
unit, helps with staff retention, and creates better outcomes for the patients (Strover et al., 2019).
Implementing the best practices from EBP research and maintaining an innovative spirit is the best way to
achieve this goal. Implementation of central line maintenance teams provides more assessments for the
patients and provides help to the assigned nurse. More current research is needed to keep expanding this
project.
ReferencesCentral Line Maintenance Team 12
Agency for Healthcare Research and Quality. (2017, November). Estimating the Additional Hospital Inpatient Cost
and Mortality Associated with Selected Hospital-Acquired Conditions.
https://www.ahrq.gov/hai/pfp/haccost2017-results.html
Aloush, S. & Alsaraireh F. (2018). Nurses’ compliance with central line associated blood stream infection
prevention guidelines. Saudi Medical Journal, 39 (3), 273-279. https://doi.org/10.15537/smj.2018.3.21497
Bell, T. & O’Grady, N. (2017). Prevention of Central Line-Associated Bloodstream Infections. Infectious Disease
Clinics of North America 31 (3), 551-559. https://doi.org/ 10.1016/j.idc.2017.05.007
Cavalcanti, A. (2016). Effect of a quality improvement intervention with daily round checklists, goal setting, and
clinician prompting on mortality of critically ill patients: a randomized clinical trial. Caring For The
Critical Ill Patient, 315(14), 1480-1490. https://doi.org/10.1001/jama.2016.3463
Centers For Disease Control and Prevention. (2019, December). 2019 National and State Healthcare-Associated
Infections Progress Report. https://www.cdc.gov/hai/data/portal/progress-report.html#
Centers for Medicare & Medicaid Services. (2021, September). Hospital-Acquired Condition Reduction Program.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-
Program
Gunther, S., Ara-Somohano, C., Bonadona, A., Cartier, J., Chautemps, M., Hamidfar-Roy, R., Lugosi, M., Minet,
C., Potton, L., Ruckly, S., Schwebel, C., Styfalova, L., Timsit, J., Vesin. A. (2016). Complications
of intravascular catheters in ICU:Definitions, incidence and severity. A randomized controlled trial
comparing usual transparent dressings versus new-generation dressings. Intensive Care Med 42,1753–1765.
https://doi.org/10.1007/s00134-016-4582-2
Ista, E., Boersma, E., Helder, O., Hoven, B., Kornelisse, R., Starre, C. (2016). Effectiveness of insertion and
maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all
ages: A systematic review and meta-analysis. Lancet Infect Dis. 16, 724–734. http://dx.doi.org/10.1016/
S1473-3099(15)00409-0Central Line Maintenance Team 13
Karapanou, A., Vieru, A., Sampanis, M., Pantazatou, A., Deliolanis, I., Daikos, G., Samarkos, M. (2019). Failure of
central venous catheter insertion and care bundles in a high central line associated bloodstream infection
rate, high bed occupancy hospital. American Journal of Infection control, 48, 770-779.
https://doi.org/10.1016/j.ajic.2019.11.018
Legemaat, M., Hoogen, A., Jongerden, I., Rens, R., Zielman, M. (2015). Effect of a vascular access team on central
line-associated bloodstream infections in infants admitted to a neonatal intensive care unit: A systematic
review. International Journal of Nursing Studies, 52, 1003-1010.
https://dx.doi.org/10.1016/j.ijnurstu.2014.ll.010
Melnyk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and healthcare. Wolters Kluwer.
Medline At Home. (2022). https://athome.medline.com/en/readyprep-chg-2-chlorhexidine-gluconate-cloths-6ct-
msc098chgh
Perin, D., Erdmann, A., Higashi, G., Sasso, G. (2016). Evidence-based measures to prevent central line-associated
bloodstream infections: a systematic review. Revisto-Latino Americana de Enfermagem 27, 1-10.
https://doi.org/10.1590/1518-8345.1233.2787
Silva, J.T., Aguado, J. M., Fernandez-Ruiz, M., Gonzalaz-Monterrubio, G., Lagares-Velasco, A., Lopez-
Medrano, F., Perez-Cardenas, M.D. (2020). Peripherally inserted central venous catheter placed and
maintained by a dedicated nursing team for the administration of antimicrobial therapy vs. another type of
catheter: A retrospective case-control study. Enfermedades Infecciosas y Microbiologia Clinica. 3(9),
425-430. https://doi.org/10.1016/j.eimc.2020.01.005
Stroever, S., Boston, K., Cuccaro, P., Ellsworth, M., McCurdy, S. (2020). Qualitative process evaluation of a
central line-associated bloodstream infection (CLABSI) prevention team in the neonatal intensive care unit.
American Journal of Infection Control, 48, 987-992.https://doi.org/10.1016/j.ajic.2019.12.020Central Line Maintenance Team 14
Voor, A., Helder, O., Vos, M., Schafthuizen, L., Sulz, S., Hoogen, A., Ista, E. (2017). Antiseptic barrier cap
effective in reducing central line-associated bloodstream infections: A systematic review and meta-
analysis. International Journal of Nursing Studies 69, 34-40.
http://dx.doi.org/10.1016/j.ijnurstu.2017.01.007Central Line Maintenance Team 15
Central Line Maintenance Team 16
Appendix A
Synthesis Table
Level of evidence synthesis table
Level Of Evidence for KS #1 KS# 2 KS# 3 KS# 4 KS #5 KS #6
intervention questions Cavalcanti, Stroever et Legemaat et Gunther et Ista et al. Silva et al.
A. (2016) al. (2019) al. (2015) al. (2016) (2016) (2019)
I. Systemic Review X X
II. Single RCT X X
III. Quasi experimental
studies/nonrandomized
controlled trials
IV. Cohort or case-control X
studies
V. Systemic review/meta-
synthesis of qualitative studies
VI. Single qualitative or X
descriptive studies/evidence
implementation and quality
improvement projects
VII. Expert opinion
Level Of Evidence for KS #7 KS# 8 KS# 9 KS# 10 KS #11 KS #12
intervention questions Perin, D et al. Voor, A et al. Aloush, S. & Foka, M. et Bell, T. & Karapanou,
(2016) (2017) Alsaraireh, F. al. (2021( O’Grady, N. A. et al.
(2018) (2017) (2019)
I. Systemic Review X X X
II. Single RCT
III. Quasi experimental X
studies/nonrandomized
controlled trials
IV. Cohort or case-control
studies
V. Systemic review/meta-
synthesis of qualitative studies
VI. Single qualitative or X X
descriptive studies/evidence
implementation and quality
improvement projects
VII. Expert opinionCentral Line Maintenance Team 17
Impact of outcome synthesis table
Study Year Number of Study Intervention Impact of
Author participants Design outcomes
Cavalcanti, 2016 6877 R Checklist and
A., et al. multidisciplinary
rounds
Boston, K., 2020 25 Q Interviews
et al.
Hoogen, A. 2015 414 S Vascular access
et al. team
Ara- 2016 670 R CHG impregnated
Somohano, dressings
C. et al.
Boersma, 2015 2370 S Central line
E., et al. bundles
Aguado, J., 2020 100 C PICC insertion and
et al maintenance team
KS #7 2020 34 S ICU care bundles
Perin, D et al.
KS#8 2017 9 S Antiseptic barrier
Voor, A et al.
caps
KS #9 Aloush, 2018 171 D Compliance of
S. &
Alsaraireh, F.
central line bundles
KS #10 Foka, 2021 913 S Modified CVC
M. et al.
bundles
KS #11 Bell, T. 2017 N/A E EBP guidelines for
& O’Grady, N.
CVC bundles
Karapanou, A. 2019 574 Q EBP bundle
et al.
compliance
= no effect, = increased, = decreased
C= cohort study, D= descriptive study, E = EBP implementation, EBP = evidence based practice,
KS= keeper study, Q= qualitative study, R= randomized control study, S= systemic review,Central Line Maintenance Team 18
Appendix B
Flowchart
Fall 2020: Spring 2021: Fall 2021: Beginning of
Inquiry and PICOT Continued PICOT question Spring 2022
Step 0-3:
Step 2-3:
question evidence search revamped with Dr. •Project decision for it
Step 5:
Step 4:
developed. and critical to a benchmark study
Gaw.
Evidence search, appraisals. •evaluated potential
EBP change paper outcomes
critical appraisals Evaluation and written •6 more articles of
began. synthesis tables supporting evidence
created. found
End of Spring 2022
•DisseminationCentral Line Maintenance Team 19
Appendix C
Instrument
To place in patient’s room for daily assessment
Patient’s initials and DOB: Central line placement date: Central line removal date:
Date and Explanation Site and Daily CHG Central Daily X- Curos
initial of for why central dressing bath line and ray caps in
person line not assessment: completed? IV completed? place?
completing removed: tubing
assessment: labeled?
Interview questions for staff:
This can be uploaded via QR code reader.
Has your workflow
improved?
What suggestions do you
have for the new process?
What is your perception of
the central line maintenance
plan?
Trending chart to be turned into a bar graph:
Pre-intervention Post-intervention
CLASBI incidences
Compliance with
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