Posted: September 4th, 2022

QI Project



Our Unit

Comparison Unit

Comparison Unit




















































Multi-Drug Resistant Infections (MRSA)

In the state of Indiana, our multi-drug resistant infections (MDRI) started to rise in 2018. Our hospital has experienced the same rise, especially in MRSA patients. Prior to 2018, our MRSA rates were stable at 1.3% of all surgical patients. In 2021, our rates rose to 7.8% and so far in 2022 our rates are 11.8%.

We are required to count MRSA rates as any patient who had surgery in the past 60 days that was discharged from our facility, then returned with a MRSA positive infection. This can be MRSA at the site of surgery, in the bloodstream, or anywhere in the body that resulted in a positive culture.

Our surgical patients are required to shower the day of surgery with soap and water. Pre-operatively, we cleanse the site with a chlorhexidine swab prior to the surgical incision. The sterile field is maintained throughout surgery. Our surgical suites are designed with airflow that does not go move over the surgical site. We have noticed that none of the surgical cases that return with MRSA are in one surgical suite and are not associated with any one doctor or surgical team.

Post-operatively, a nurse is required to assess the wound daily and document the site and any draining in the EMR. The patient is given supplies upon discharge of two dressing changes and are taught how to clean the site. We have 100% compliance with handwashing post-op as witnessed by our quality department.

We need to know what are the best practices for reducing MRSA infections. We would also like to know what procedures need to be changed and how we can fix our problem.



QI Project:


Jhoana La Rosa, Syeda Tariq, and Mitchell Vitzthum

Purdue University Northwest

NUR 45200: Quality and Safety for Professional Nursing Practice


Background of the Problem

A central line-associated bloodstream infection (CLABSI) is defined as a laboratory-

confirmed bloodstream infection not related to an infection at another site that develops within

48 hours of central line (CL) placement. CLABSIs are prevalent in the intensive care unit (ICU)

in the United States. An estimated 0.8 CLABSIs per 1000 CL days occur in ICUs. Over 28,000

die from CLABSI each year and costs over $2 billion. CLABSI continues to be a high-cost

burden. However, evidence shows that with proper aseptic techniques, monitoring, and

maintenance strategies, CLABSI is preventable (Haddadin et al., 2021).

There are two types of central line: tunneled catheter and non-tunneled catheter.

Tunneled catheters are inserted surgically by creating a subcutaneous track into the internal

jugular, subclavian, or femoral vein for long-term use such as chemotherapy or hemodialysis.

They stay on for weeks or months. The other type of central line, non-tunneled catheters, are

more commonly used, but they are temporary only. They are inserted percutaneously, and they

account for most CLABSI episodes. Within 7 to 10 days of insertion, bacteria on the skin

surface migrate along the external surface of the catheter from the skin exit site towards the

intravascular space. Unlike non-tunneled catheters, tunneled catheters have a cuff that creates a

barrier to bacterial migration. It is the absence of a tunnel that places non-tunneled catheters at

higher risk for CLABSIs (Haddadin et al., 2021).

Case Scenario

Our central line-associated blood stream infection (CLABSI) rates are different in our

two ICU units; cardiovascular ICU (CVICU) and our regular ICU (ICU). Both units have the

same protocol of cleansing the area with hexachlorophene sponges every 72 hours when

changing the dressing. This is the only time the dressing is changed. Otherwise, the nurse looks


at the site for redness or any issues with drainage from the site and charts it in the documentation

system every four hours.

The number of patients with central lines is the same for both units. When speaking with

CVICU nurses, they said that the only thing they do differently from the protocol is to change the

dressing once a day, using hexachlorophene sponges during the dressing change. The ICU nurses

state that they have leftover betadine sponges that they are trying to use up before switching to

the hexachlorophene sponges. They had ten cases of the betadine sponges that could not be

returned so to promote cost-effectiveness, they decided as a unit to finish up the cases. The

hospital switched to hexachorophene sponges in the second quarter of the year. We currently

have no way to quickly identify those patients with CLABSIs since the only way to determine if

one is present is to remove the catheter and culture it.

We want to know if our protocol is the best way to care for patients with central lines.

PICO Question

Our group formulated the PICO question: In adult ICU patients with central line

(population), does implementing evidence-based interventions (intervention), compared to not

using evidence-based interventions (comparison), reduce CLABSIs (outcome)?

Search Strategy

To find the best evidence-based strategies to prevent CLABSIs, a literary search was

performed in CINAHL database. Keywords such as “central line,” “central venous catheter*,”

“PICC line*,” “CHG sponge*,” “hexachlorophene sponge*,” “evidence-based intervention*,”

“infection*,” “CLABSI,” and “central line-associated bloodstream infection” were used.

Those keywords did not yield a lot of results, so new search terms were added such as

“evidence-based intervention*,” “adult patient*,” “adult*,” “patient*,” “evidence-based


practice,” “evidence-based preventive strategies,” and “preventive strategies.” This time, the

new search terms yielded more articles.

Limiters were also added such as peer-reviewed journals, English Language, and

published after 2021.


Our group has selected two articles, a systematic review and a quality improvement

project. JBI critical appraisal tool was used to review the systematic review, and Based on these

reports, the best strategies to prevent or reduce CLABSI rates are: CL care bundle,

Appraisal Tool 1

The first article was reviewed by using the JBI Critical Appraisal Tool for systematic


The appraisal tool was used for the following reference:

Alanazi, T. N. M., Alharbi, K. A. S., Alrawaili, A. B. R., & Arishi, A. A. M. (2021).

Preventive strategies for the reduction of central line-associated bloodstream infections in

adult intensive care units: A systematic review. Collegian: Journal of the Royal College

of Nursing, 28(4)

Yes No Unclear


1. Is the review question clearly and explicitly stated? x □ □ □
2. Were the inclusion criteria appropriate for the review

question? x □ □ □
3. Was the search strategy appropriate? x □ □ □
4. Were the sources and resources used to search for

studies adequate? x □ □ □


5. Were the criteria for appraising studies appropriate? x □ □ □
6. Was critical appraisal conducted by two or more

reviewers independently? x □ □ □
7. Were there methods to minimize errors in data

extraction? x □ □ □
8. Were the methods used to combine studies

appropriate? x □ □ □
9. Was the likelihood of publication bias assessed? x □ □ □
10. Were recommendations for policy and/or practice

supported by the reported data? x □ □ □
11. Were the specific directives for new research

appropriate? x □ □ □
Overall appraisal: Include □ Exclude □ Seek further info □
Comments (Including reason for exclusion)




1. The review question is clearly and explicitly stated in the Aim section of the article on p.

438. It covers the PICO elements: P – adult ICU patients; I – implementing evidence-

based interventions; C (none identified); and O – reduce CLABSIs.

2. The inclusion criteria were appropriate for the review question. The inclusion criteria

include the following: studies conducted in adult ICUs; studies utilizing all available

interventions to prevent/reduce CLABSI rates as recommended by the Centres of Control

and Disease Prevention and the Institute for Healthcare Improvement compilation of

bundle of interventions to reduce CLABSIs; and studies published from 2016 to 2020

(Alanazi et al., 2021, p. 439).


3. The search strategy was appropriate. CINAHL, MEDLINE, Scopus, and Science Direct

were used to search for the key terms: ‘bloodstream’, ‘central line’, ‘infection’,

‘prevention’, and ‘reduction’ Alanazi et

al., 2021, p. 439).

4. The sources and resources used to search for studies were adequate. The search returned

158 results. They were further reviewed and 15 studies were finally included in this

review (Alanazi et al., 2021, pp. 439-440).

5. The criteria for appraising the studies were appropriate. Studies that included a

combination of CLABSI and catheter-associated urinary tract infection, all catheter-

associated bloodstream infections, peripherally inserted central catheters, or no


of the prevention of CLABSIs were excluded from this review (Alanazi et al.,

2021, p. 440).

6. The critical appraisal was conducted by two researchers independently as described in the

Search Strategy section of the article on p. 439.

7. Methods were used to minimize errors in data extraction. Please refer to #5 answer.

8. Methods used to combine studies were appropriate. The researchers categorized the

findings according to the evidence-based preventive measures for CLABSI. Categories

include CL care bundle, chlorhexidine and silver-plated dressing effectiveness, infection

control and multidisciplinary interventions, and mandatory reporting laws on healthcare-

associated infections (Alanazi et al., 2021, p. 440).

9. The likelihood of publication bias was assessed. The report states that no single

randomized controlled trial study was found to be eligible for inclusion in this review

even though they were highly rated in the hierarchy of the evidence pyramid due to low

risk of bias (Alanazi et al., 2021, p. 440).


10. Recommendations for policy and and/or practice were supported by the reported data.

The evidence-based interventions included in this review were proven to be effective in

reducing CLABSIs. The review states that the nurses, nurse educators, hospital leaders,

and administrators may use the evidence-based CLABSI preventive interventions

described in this review to reduce CLABSIs and hospital costs. It also suggests

incorporating these guidelines in nursing schools.

11. Specific directives for new research were appropriate. CLABSIs have been a major in

hospital ICUs. Previous studies show that CLABSI rates have been decreasing over the

years, but zero CLABSI rate is also achievable, and that is the ultimate goal (Alanazi et

al., 2021, p. 439).

Appraisal Tool 2

The second article was reviewed by using the JMLA Evidence Summary Appraisal Tool.

The appraisal tool was used for the following reference:

Rives, S. A., Shamailov, M., Rozman, P., Garazatua, R., Vinski, J., & Siegmund, L. A. (2021).

Decreasing central line infections on a medical-surgical unit. MEDSURG Nursing,

30(5), 303–31


QUESTIONS (guiding questions)

Summary topic

1. Is the summary specific in scope and application? Yes, the quality improvement project

focused on decreasing the prevalence of CLABSI.


– Are clinical questions covered by the summary specifically described? Yes, the summary

mentions how successful QI projects to decrease CLABSI have focused around CLABSI care

bundle measures such as the approach to dressing changes.

– Are patients the summary applies to described? Yes, unfortunately this study focuses on

CLABSI on medical surgical units as opposed to ICU patients.

Summary methods

2. Is the authorship of the summary transparent? – Are individual authors listed?


– Are credentials of author(s) listed? Yes, five out of the six authors have a master’s degree, four

of those degrees are in nursing. The sixth author listed has a PhD.

– Are affiliations of author(s) listed Yes, all authors are affiliated with the Cleveland Clinic of


– Is the process to become an author described? No, this process has not been described.

3. Are the reviewer(s)/editor(s) of the summary transparent? The project was published In

Medsurg Nursing.

– Are the summaries edited/reviewed? This information is unknown.

– Are individual reviewers listed? No, the individual reviewers are not listed.

– Are credentials of reviewer(s) listed? No there are no credentials listed, because the reviewers

are not listed.

– Are affiliations of reviewer(s) listed? no

– Is the process to be a reviewer described?


4. Are the search methods transparent and comprehensive? The search methods for recourses

were not listed in the project.

– Are the inclusion criteria for selected studies clearly described? The Inclusion criteria for this


specific study was “Patients with acute and chronic digestive disease on five surgical units/one

medical unit” (Rives, et. al, 2021).

– Are the sources of the search provided? The databases and sources of the searched articles are

not provided.

– Is the search thorough enough to find all the relevant studies? N/A

– Are search terms listed? No, the search terms are not listed.

5. Is the evidence graded and is the system transparent and translatable – Is the system clearly

described? Yes, the evidence is transparent and clearly described using statistics.

– Is the system based on a standard? The quality improvement method used was based on Plan,

Do, Check, Adjust (PDCA) (Shook, 2008)

– Is there a grade for each recommendation and/or cited study? There Is no grade for each

recommendation and/or cited study.

– Are the grade labels easy to interpret? N/A

Summary content

6. Are the recommendations clear? Yes, the recommendations are very clear.

– Are recommendations clearly described? The recommendations are described as needing more

interprofessional collaboration. For example, one recommendation says, “Start with strong

interprofessional participation and provider leadership to address discipline-specific aspects of

line care (e.g., line discontinuation)” (Rives, et. al, 2021)

– Are multiple options for treatment provided? Multiple care Interventions are listed to decrease

CLABSI rates.

7. Are the recommendations appropriately cited? Yes, recommendations are appropriately cited.

– Are citations provided? Yes, there are multiple citations provided.


– Is there an explicit link between the summary text and supporting evidence? Yes, there are

citations that support the link between summary text and supporting evidence.

8. Are the recommendations current? Yes, the article was published in 2021.

– Has the summary been updated within the last 2 years? No.

9. Is the summary free of possible bias? There is large possibility for bias because the

implementation took place at one facility with all authors affiliated with the Mayo Clinic.

– Is there a conflict of interest between the recommendations of the summary

and the sponsor for any author or reviewer? There is no conflict of Interest though because the

results were not necessarily positive. The QI project was not able to decrease CLABSI

occurrence by 10% as planned, one year It actually increased slightly.

Summary application

10. Can this summary be applied to your patient(s)? Yes, active rounding can be done to assure

bundle measures are compliant.

– Does the evidence cover your patient(s) or a similar population? Our patient population is not

the same because we are focused on ICU rather than a medsurg floor.

– Does the evidence cover your setting or similar setting? The setting is similar in that it is in the

hospital on an acute care floor.

– Can you translate the recommendations treatment plan for your patient(s)? Assessments of

central line maintenance CLABSI bundle care practices were completed weekly.

Levels of Evidence

The level of evidence (LOE) using the hierarchy of evidence for the first article is Level 1

because the evidence comes from a systematic review. The second article is also a Level 1

because the evidence is based on clinical practice guidelines.


Analysis of Current Condition

Monthly Audit Data: CLABSI

Unit A CVICU Unit B


Jan 2.8


Feb 1.6


Mar 1.12


Apr 0.8


May 3.7 5.7

June 1 5.8

July 0.2


Aug 0.1


Sept 0.9 8.1

Oct 1.2 7.9

Nov 0.1


Dec 0


*per 1,000 pt days


Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec






0.2 0.1

0.9 1.2

0.1 0





5.7 5.8



8.1 7.9




Unit A CVICU Column1

Line chart displaying the incidences of CLABSI in Unit A (CVICU) and Unit B (ICU)

Monthly Audit Data

Based on the monthly audit data from the case scenario above, CLABSI rates in CVICU

are lower than regular ICU. The CLABSI episodes per 1,000 patient days in CVICU were 2.8

CLABSI in January and zero (0) in


Regular ICU had 4.7 in January and 5.23 in




The flowchart above describes the current process combined with the central line (CL)

care bundle that the evidence suggests. According to the flowchart above, if a patient has a CL,

the RN will assess the site, dressing, and administration set. If there are no signs of infection,

and the dressing and administration set are clean and not due for changing, then the RN caring

for the patient with CL is bundle compliant. Nothing else needs to be done except document. If

the dressing and administration set need changing, then the RN must be competent in changing

Patient has a
Central Line

bundle Compliant

Assess central line, dressing, and
IV tubing.

Is the dressing
clean, dry, intact

occlusive, and
less than 7 days



Are you 100%

confident in your
knowledge of how
to appropriately
change a central

line dressing?


Find another nurse who is
and can teach you.

Gather supplies to
change dressing.


Are all the supplies available
and within expiration date?

NO Yes




Has the patient

received CHG bath
within 24 hours?


Change the
dressing using
best practice






lines and dressing. If not, then the RN must consult with an RN who is competent and

knowledgeable in changing lines and dressing. Supplies for changing lines and dressing must be

checked for expiration dates. If expired or not available, supplies must be requested from central

supply department immediately. Before, changing the lines and dressing, the RN must make

sure that the patient has received a CHG bath within the last 24 hours. If not, then CHG bath

should be given prior to changing lines and dressing. The RN must also use make sure to

practice hand hygiene and use aseptic technique when caring for CLs. If these measures are

followed, then the RN is bundle compliant.

Cause Analysis


Q I E S S E N T I A L S T O O L K I T : C a u s e a n d E ffe c t D i a g r a m

I n s t i t u t e f o r H e a l t h c a r e I m p r o v e m e n t ∙ i h i . o r g

B e f o r e f i l l i n g o u t t h i s t e m p l a t e , f i r s t s a v e t h e f i l e o n y o u r c o m p u t e r . T h e n o p e n a n d u s e t h a t v e r s i o n o f t h e t o o l . O t h e r w i s e , y o u r c h a n g e s w i l l n o t b e s a v e d .

T e m p l a t e : C a u s e a n d E f f e c t D i a g r a m

P e o p l e E n v i r o n m e n t

M a t e r i a l s M e t h o d s E q u i p m e n t

G r o u p 1 0


P e o p l e E n v i r o n m e n t

M a t e r i a l s M e t h o d s

r e s t l e s s p a t i e n t N o n – i n v o l v e d s t a ff
e n t e r i n g s t e r i l e fie l d

n o n – s t e r i l e fie l d a i r b o r n e p a t h o g e n s

o v e r w o r k e d s t a ff u n t r a i n e d o r u n d e r t r a i n e d
s t a ff

u n k e p t d i r t y r o o m

L a c k o f s u p p l i e s

e x p i r e d s u p p l i e s

n o n – s t e r i l e s u p p l i e s

m i s l a b e l e d m a t e r i a l s

o u t o f d a t e p r a c t i c e s

i m p r o p e r t e c h n i q u e

i n c o m p l e t e d r e s s i n g c h a n g e

l e n t h o f t i m e b e t w e e n
d r e s s i n g c h a n g e s

i n – p r o p e r P P E f o r p a t i e n t a n d
s t a ff

I n p r o p e r w o r k i n g h e i g h t o f
b e d .

n o n s t e r i l e g l o v e s

n o n – o c c l u s i v e d r e s s i n g

E q u i p m e n t



Fishbone Diagram

CLs increase the risk of acquiring CLABSIs among adult patients in the ICU. Healthcare

providers have a big responsibility when it comes to maintaining the central lines and making

sure they are following protocols to prevent CLABSIs. However, there are a lot of factors

contributing to the increase of CLABSI rates. As shown on the fishbone diagram above, causes

of CLABSI are categorized as: people, environment, materials, methods, and equipment.

Some of the causes under “people” are undertrained staff and overworked staff.

According to Haddadin et al. (2021), audits of doctors who insert central lines and nurses who

maintain the lines is vital to ensure compliance with evidence-based guidelines. Lee at al. (2018)

suggest that by establishing reasonable workloads and prioritizing quality, CLABSI rates will be

reduced. According to Sheth et al. (2017), inadequate hand hygiene by staff and their lack of

skill and experience are risk factors for CLABSI.

When it comes to device or line insertion, Wong reports that inadequate sterile barrier

precautions, internal jugular and femoral venous access, antimicrobial device coating, prolonged

catheter dwell times, multiple CLs, and frequent accessing of lumens are causing CLABSIs.

A prospective observational study was conducted in an adult intensive care unit in India

over a period of 16 months to evaluate the risk factors associated with CLABSI. A total of 861

blood samples were collected in culture vials. A total of 55 microorganisms were recovered.

The Gram-negative pathogens found include Klebsiella pneumoniae, Pseudomonas aeruginosa,

Acinetobacter species, Stenotrophomonas maltophilia, Proteus species, Pantoea agglomerans,

Sphingobacterium maltivorum, and Porphyromonas species. The Gram-positive microorganisms

found were Staphylococcus aureus and Enterococcus species (Mishra et al., 2017).


Although, the patients may also contribute to the risk of CLABSI. One of the causes

indicated on the fishbone diagram above is “restless patient.” Other host factors that increase the

risk of CLABSI include hemodialysis, malignancy, gastrointestinal disorders, pulmonary

hypertension, diabetes, malnutrition, total parenteral nutrition, old age, loss of skin integrity, and

prolonged hospitalization before insertion (Haddadin et al., 2021).

Action Plan

Structure or Process Indicators:

Indicator What data will be


Central line (CL) care bundle

Weekly audits


Silver-plated dressings

Scan barcode on

packaging per use


Positive displacement

needleless connectors

Scan barcode on

packaging per use


Constant personnel education Periodical


assessment and



Plan for Improvement

Indicator 1: _________CL Care Bundle____________________________________________

This is key to improving outcomes because: Many evidence-based strategies, including CL

care bundle, have been proven to prevent or reduce CLABSIs. The elements in the CL care

bundle assessment tool include hand hygiene, aseptic technique, maximal sterile barrier

precautions, best insertion site, preparing site with chlorhexidine with alcohol, placing sterile

gauze dressing, using chlorhexidine-impregnated dressing, bathing patients with chlorhexidine

prep daily, scrubbing access port or hub with antiseptic, using sterile devices to access catheters,

replacing soiled dressings immediately, changing dressings at least every 7 days, changing

administration sets for continuous infusions no more frequently than every 4 days but at least

every 7 days, daily audits, regular healthcare personnel education and periodical knowledge

assessment, antimicrobial impregnated catheters, and antiseptic impregnated caps for access

ports (CDC, 2011).

Operational definition: All ICU RN’s caring for patients with CL must comply with the CL

care bundle protocol when inserting a new CL and must audit adherence weekly using the CL

Assessment tool

Numerator: RN’s in ICU using CL care bundle on patients with CL

Denominator: All RN’s in ICU caring for patients with CL

Goal for this indicator: All ICU RN’s taking care of patients with CL will adhere to CL care

bundle protocol

Benchmark: 100% compliance, 0 CLABSIs

Data collection method:





Follow CL care bundle protocol and audit using CL Assessment tool




CL care bundle has been reported to prevent or reduce CLABSIs in ICU


When inserting a new CL, changing administration set and dressing, and

auditing weekly


When inserting a new CL, RN will use CL assessment tool. During weekly

rounds, each patient with CL will be identified; RN will evaluate each CL using

the assessment tool; time and date the assessment tool and sign


Indicator 2: _____________Silver plated dressin gs ____________________________________

This is key to improving outcomes because: Silver nitrate has been documented as a

therapeutic agent by the Roman civilization in their medical books, and silver has been widely

used in different forms in medicine today. Studies show that the use of silver-plated dressings

has decreased CLABSIs in ICUs in the United States (Karinoski et al., 2019).

Operational definition: All ICU RN’s caring for patients with CL must scan and document type

of dressing used for CL for proper monitoring

Numerator: ICU patients with silver-plated dressing for their CL

Denominator: All ICU patients with CL

Goal for this indicator: All ICU RN’s caring for patients with CL will adhere to new protocols

of using silver plated dressings by scanning and documenting the type of dressing used

Benchmark: 100% compliance, 0 CLABSIs

Data collection method:




Scan and document type of dressing used for

central line




Studies show that the use of silver-plated dressings has decreased CLABSIs in


ICUs in the United States.


When central line is inserted and when dressing is changed (every 7 days and

as needed [Karinoski et al., 2019]).


Scan barcode on silver dressing packaging; cover central line site with silver-

plated dressing; date and time the dressing; document in chart

Indicator 3: ________________Positive displacement needleless connector_______________

This is key to improving outcomes because: Studies show that zero CLABSI can be achieved

with the use of positive displacement needleless connectors. Needleless connectors (NCs) are

devices that connect the end of catheters and enable access for infusion and aspiration (Curran,


Operational definition: All ICU RN’s must scan and document each use of positive

displacement needless connector when inserting a new CL or when a new administration set is


Numerator: ICU patients with positive displacement needleless connectors for their

central line

Denominator: All ICU patients with CL


Goal for this indicator: All ICU RN’s caring for patients with CL will adhere to new protocols

of using positive displacement needleless connectors by scanning and documenting type of

attachment device

Benchmark: 100% compliance, 0 CLABSIs

Data collection method:




Scan and document each use of positive displacement needless connector




Studies show that zero CLABSI can be achieved with the use of positive

needleless connectors


When central line is inserted and when administration set is changed (no more

often than every 72 hours [TJC, 2013]).


Scan barcode on needleless connector packaging; document in chart


Indicator 4: ______________Constant personnel education___________________________

This is key to improving outcomes because: Evidence shows that constant education of ICU

personnel could reduce

CLABSIs (Alanazi et al., 2021)

Operational definition: All ICU staff must take continuing education refresher course each

year on central line care.

Numerator: ICU personnel competent in insertion and maintenance of CLs

Denominator: All ICU personnel

Goal for this indicator: All ICU RN’s will score greater than 80% on CL

knowledge assessment

periodically at least annually.

Benchmark: 100% compliance, 0 CLABSIs

Data collection method:


Unit Manager and educator


Educate ICU personnel on proper insertion and maintenance of CLs, and

conduct assessments of knowledge periodically (CDC, 2011)




Evidence shows that constant education of ICU personnel could reduce


CLABSIs (Alanazi et al., 2021)




Mandate education on proper CL insertion and maintenance as well as

knowledge assessment


Alanazi, T. N. M., Alharbi, K. A. S., Alrawaili, A. B. R., & Arishi, A. A. M. (2021). Preventive

strategies for the reduction of central line-associated bloodstream infections in adult

intensive care units: A systematic review. Collegian: Journal of the Royal College of

Nursing, 28(4).


Centers for Disease Control and Prevention (CDC). (2011). Checklist for prevention of central

line associated blood stream infections. Healthcare-Associated Infections (HAIs).

Curran, E. (2016). Needleless connectors: the vascular access catheter’s microbial gatekeeper.

Journal of infection prevention, 17(5), 234–240.

Haddadin, Y., Annamaraju, P., & Regunath, H. (2021). Central line associated blood stream

infections. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:

Karlnoski, R., Abboud, E. C., Thompson, P., Oxner, A. Z., Sinnott, J. T., & Marcet, J. E. (2019).

Reduction in central line–associated bloodstream infections correlated with the

introduction of a novel silver-plated dressing for central venous catheters and maintained

for 6 years. Journal of Intensive Care Medicine, 34(7), 544–549.

Lee, Y., Stone, P., Pogorzelska-Maziarz, M., & Nembhard, I. (2018). Differences in work

environment for staff as an explanation for variation in central line bundle compliance in

intensive care units. Health Care Management Review, 43(2).

Mishra, S. B., Misra, R., Azim, A., Baronia, A. K., Prasad, K. N., Dhole, T. N., Gurjar, M.,

Singh, R. K., & Poddar, B. (2017). Incidence, risk factors and associated mortality of

central line-associated bloodstream infections at an intensive care unit in northern India.

International Journal for Quality in Health Care, 29(1).


Rives, S. A., Shamailov, M., Rozman, P., Garazatua, R., Vinski, J., & Siegmund, L. A. (2021).

Decreasing central line infections on a medical-surgical unit. MEDSURG Nursing,

30(5), 303–313.

Shook, J. (2008). Managing to learn: Using the A3 management process. Lean Enter – prise

Institute, Inc

Sheth, H., Trifan, A., Feterik, K., & Jovin, F. (2017). Expanding central line care bundle to

address line manipulations. Canadian Journal of Infection Control, 32(4), 217–221.

The Joint Commission (TJC). (2013). Preventing central line–associated bloodstream

infections: Useful tools. An International Perspective.

UpToDate. (2022). Non-tunneled versus tunneled central venous catheter. UpToDate, Inc.



Wong, S. W., Gantner, D., McGloughlin, S., Leong, T., Worth, L. J., Klintworth, G.,

Scheinkestel, C., Pilcher, D., Cheng, A. C., & Udy, A. A. (2016). The influence of

intensive care unit-acquired central line-associated bloodstream infection on in-hospital

mortality: A single-center risk-adjusted analysis. American Journal of Infection Control,


Names and Contributions

Names and Summary of Group Member Assignment Contributions:
Jhoana La Rosa – Completed the assignment on her own and worked with other group
members to consolidate information for the final appraisal document.
Syeda Tariq – Completed the assignment on her own and worked with other group


members to consolidate information for the final appraisal document.
Mitchell Vitzthum – Completed the assignment on his own and worked with other group
members to consolidate information for the final appraisal document.

Requirements for QI Report of Project: Written

Background of the problem 

· Definition of the problem with references

· Depth and breadth of the problem (e.g., national statistics and local data to demonstrate a problem exists)

· PICO question and search strategy


· What evidence did you find? Synthesize the evidence

· Appraisal of the evidence using appropriate appraisal tools

· Levels of evidence using hierarchy of evidence

Analysis of Current Condition

· Table and graph with narrative (use data from assigned problem)

· Flowchart comparing current process versus what evidence says should be done with narrative identifying missed opportunities (indicators).

Cause Analysis 

· Root Cause Analysis with Fishbone Diagram. Identify where the problems exist. Describe causes for the problem and how each is linked to the problem.

Action Plan for Each Indicator

· Changes that should be done in order to improve practice, according to what evidence shows. Include:

· Indicator (look at your indicator sheet): Provide the evidence to support in one sentence.

· Measurement: Numerator and denominator. How will you measure that the change is being done?

· Goal: What is your goal data? Benchmarks?


Implementation:  Include best practices for implementing your change with evidence to support your implementation strategy

· Create a table with the following information for each indicator:






Completion Date

Describe who is responsible

Explain what they are responsible for. Address each indicator

Rationale for why this person(s) should be responsible for this action

When will they perform the action? What is the timeline for completing the task?

Explain how the person should complete the assignment (think of implementation described above)

Date for completing the action

Reference Page

Names and Contributions

Names and Summary of Group Member Assignment Contributions:


MMK 2020

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