Running Header: PICO Statement and Literature Search


PICO Statement and Literature Search

NRS 433-V

Grand Canyon University

Literature Search

In researching articles for this paper, I turned to both Qualitative and Quantitative peer reviewed articles. I also performed a lot of independent research so I could knowledgably select the best articles for this research. According to the United States Centers for Disease Control and the Society for Healthcare Epidemiology of America and the Disease Society of America (SHEA-IDSA) report, the most common Healthcare Associated Infection are Central Line Associated Blood Stream Infections or CLABSI. With nearly 50% of all ICU patients requiring a central line, the amount of recorded CLABSI infections is extremely high. The research on CLABSI indicates the most common pathogens are Staphylococcus Aureus, Enterococci, and Candida. To better understand the nature of CLABSI incidence and therefore employ prevention strategies we must understand the dynamics of a central line. The National Healthcare Safety Network defines a central line as “a catheter whose tip terminates in a great vessel” (IHI, 2011). The catheter on a central line punctures the skin, which by default makes bacterial and fungal infections possible. Once the infection has entered the body it can spread to the blood stream. The infection can then cause hemodynamic changes possibly causing death of a patient. Proof of an infection is found in the recovery of a pathogen from a blood culture from a patient who had a central line. For declarative purposes, a pathogen not commonly present on the skin must only be found in one culture whereas a pathogen commonly found on the skin must be detected in two or more cultures.

To be confirmed as a central line infection, the central line must have been installed a minimum of two days prior to the development of the infection and there must be no other apparent source of the infection. Regarding the cost of Healthcare Associated Infections; both are indicators of the enormity of the problem. The 2010 CDC report titled “Preventing Healthcare-Associated Infections” stated 1.7 million cases occur each year in the United States. According to the same report 99,000 cases result in death. The Institute for Healthcare Improvement estimates that of these 99,000 deaths, up to 4,000 are a direct result of bloodstream infections. The human cost is much greater than the financial costs, which alone have a crippling effect on the healthcare industry. Reflecting on the Institute for Healthcare Improvement report, each CLABSI incident prolongs hospitalization on average of seven days. Each infection costs between $3,700 and $29,000. Having established the common CLABSI incidents, identifying the risk of infection, and examining the cost, the healthcare staff must move into prevention strategies.

PICO Parts and PICO Question


P- Patients developing central line associated bloodstream infections (CLABSI).

I- Chlorohexidine daily bath to decrease CLABSI

C- Regular bath with soap and water

O- Decreased rates of CLABSI infections in patients with Central vein catheters.

Research Question

In hospitalized patients with central access devices (P), what is the effect of daily chlorohexidine baths (I) on decreasing incidence of CLABSI infections (O) compared with daily baths with soap and water (C) within a hospital stay (T)?

Six (6) Peer Reviewed Research Articles

Quantitative with Abstract-

Curlej, MH. 2016. One Rural Hospital’s Experience Implementing the Society for Healthcare Epidemiology of America Guidelines to Decrease Central Line Infections. Journal of Trauma Nursing. 23 (5):290-297.


In an effort to take advantage of the Highmark Quality Blue Initiative requiring information from hospitals detailing their central line-associated blood stream infections (CLABSIs) surveillance system, quality improvement program, and statistics regarding the CLABSI events, our institution investigated the latest evidence-based recommendations to reduce CLABSIs. Recognizing the baseline rate of 2.4 CLABSIs per 1,000 central line days and its effect on patient outcomes and medical costs, our hospital made a commitment to improve their CLABSI outcomes. As a result, we adopted the Society for Healthcare Epidemiology of America (SHEA) guidelines. The purpose of this article is to review the CLABSI rates and examine the prevention strategies following implementation of the SHEA guidelines. A quantitative, descriptive retrospective program evaluation examined the hospital’s pre- and post-SHEA implementation methods of decreasing CLABSIs and the subsequent CLABSI rates over 3-time periods. Any patient with a CLABSI infection admitted to our hospital July 2007 to June 2010 (N = 78). CLABSI rates decreased from 1.9 to 1.3 over our study period. Compliance with specific SHEA guidelines was evaluated and measures were put into place to increase compliance where necessary. CLABSI rates at our facility remain below the baseline of 2.4 for calendar year 2013 (0.79), 2014 (0.07), and 2015 (0.33).

Evans HL, Dellit TH, Chan J, Nathens AB, Maier RV, Cuschieri J. Effect of Chlorhexidine Whole-Body Bathing on Hospital-Acquired Infections Among Trauma Patients. Arch Surg. 2010;145(3):240–246.doi:10.1001/archsurg.2010.5


Objective: To demonstrate whether daily bathing with cloths impregnated with 2% chlorhexidine gluconate will decrease colonization of resistant bacteria and reduce the rates of health care–associated infections in critically injured patients. Patients: Two hundred eighty-six severely injured patients underwent daily chlorhexidine bathing during the 6-month intervention; 253 patients were bathed without chlorhexidine prior to the intervention. Outcome: Our study showed that daily bathing of trauma patients with cloths impregnated with 2% chlorhexidine gluconate is associated with a decreased rate of colonization by MRSA and Acinetobacter and lower rates of catheter-related bloodstream infection and MRSA VAP.

Hoffman, J. 2016. Daily Chlorhexidine Gluconate Bathing Reduces CLABSI Rates. Oncology Nurse Advisor. 2016, April. Retrieved from


Daily chlorhexidine gluconate (CHG) bathing on all of our patients with ports and tunneled catheters decreased the rates of central line bloodstream infections (CLABSI) on the inpatient oncology unit, in our study that was presented at the Oncology Nursing Symposium 41st Annual Congress. The study has shown “CLABSI is a preventable adverse event that affects quality of life, causes economic burden on the patient and health care system, and may even result in death,” said Helen Jackson, MSN, APRN-CNS, GCNS-BC, a clinical nurse specialist at Nebraska Methodist Hospital in Omaha. Prevention of CLABSI should be a front-line focus for all oncology units.

IHI Implementing the IHI Central Line Bundle. Retrieved from /Pages/Changes/Implement theCentralLineBundle.aspx. Institute for Healthcare Improvement. (2/24/18).

IHI Central Line Bundle: Hand Hygiene. Retrieved from /Changes/HandHygiene.aspx. Institute for Healthcare Improvement, (2/24/18).

IHI Central Line Bundle: Maximal Barrier Precautions Upon Insertion. Retrieved from Insertion.aspx. Institute for Healthcare Improvement, (2/24/18).

IHI Central Line Bundle: Chlorhexidine Skin Antisepsis. Retrieved from knowledge/Pages/Changes/ChlorhexidineSkinAntisepsis.aspx Institute for Healthcare Improvement, (2/24/18).

Qualitative with Abstract

AHRQ. 2012. Eliminating CLABSI, A National Patient Safety Imperative: Final Report. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD.


In 2003, AHRQ funded a highly successful program to use evidence-based interventions and a patient safety model called the Comprehensive Unit-based Safety Program (CUSP) to prevent central line-associated blood stream infections (CLABSI) and ventilator-associated pneumonia, and to improve the culture of safety in 127 intensive care units (ICUs) across Michigan. MHA Keystone partnered with the Armstrong Institute on a 2-year initiative called the MHA Keystone: ICU project. AHRQ heralded this effort as one of their most successful projects. The MHA Keystone: ICU project reduced CLABSI in the first 18 months by 66 percent. The median CLABSI rate was 2.7 at baseline and dropped to a median of 0.0 in that period. A follow-up study published in 2010 reported that this rate of reduction was sustained for more than three years.3 The MHA Keystone: ICU project achieved these results by using a patient safety platform developed by the Armstrong Institute called CUSP and an evidence-based change package to prevent CLABSI.

Based on this success, AHRQ contracted in fall 2008 with HRET to replicate this program nationally, starting with at least 10 hospitals in each of 10 States. The contract was expanded in fall 2009 to include all 50 States, the District of Columbia, and Puerto Rico. HRET’s partners were the Armstrong Institute, MHA Keystone, and State and regional hospital associations, which in turn partnered with hospitals and units that were recruited into the program. HRET, the Armstrong Institute, and MHA Keystone staff comprised the national project team (NPT) which named the national initiative, On the CUSP: Stop BSI.

The AHRQ program goals were to: 1) reduce CLABSIs to a rate of no more than 1/1,000 central line days, and 2) to improve patient safety culture on hospital units. Each State and regional hospital association executive signed a letter committing to these goals, to assigning a staff member to serve as the State lead to coordinate the program in the State/region, to recruiting at least 10 hospitals, and to complying with data collection and performance monitoring requirements. Some States were unable to recruit 10 hospitals. For example, Delaware had only nine acute care hospitals in the State, and States in later cohorts had significant challenges recruiting hospitals because of previous work on CLABSI reduction and the perception that the On the CUSP: Stop BSI program would not be particularly beneficial. For larger states, unable to recruit 10 hospitals, the NPT decided that it was preferable to include them to disseminate CUSP. This proved to be a valuable strategy as many of the States that are in the AHA/HRET Hospital Engagement Network have expressed interest in applying the CUSP model to their Partnership for Patients work to reduce hospital-acquired conditions.

AHRQ directed HRET and the NPT to work with States to recruit both ICUs and non-ICUs, include critical access hospitals, and to attempt to recruit all 50 States, the District of Columbia, and Puerto Rico. To best accommodate the readiness of hospital associations and their members to participate and to manage available project resources, the project was rolled out in a total of six cohorts of States/regions over the 4-year contract period. Each State/region and their participating hospitals participated in the On the CUSP: Stop BSI program for approximately 24 months, with the exception of the last cohort of states, Cohort 6, which participated for approximately 20 months.

The NPT did a systematic review of the literature to arrive at a reasonable cost of CLABSI. Out of almost 850 abstracts and 150 articles, staff found 6 articles that met inclusion criteria. After weighting and adjusting to 2012 dollars, the average CLABSI cost reported in the literature was $70,696 with a range (± two standard deviations) of $40,412 to $100,980. If baseline rates would have remained stable without the study intervention, an estimated total of 2,187 to 2,419 CLABSIs were prevented over the course of the project. Assuming a 12-25 percent mortality rate, an estimated 290 to 605 deaths were prevented during the project. Lastly, an estimated $97,777,123 to $244,318,277 in excess costs were averted as well during this period. This range is like the range reflected in the Johns Hopkins CLABSI Opportunity Estimator website (range of $40,000 to $117,000 per infection).

Donskey, C., Deshpande, A. 2016. Effect of chlorhexidine bathing in preventing infections and reducing skin burden and environmental contamination: A review of the literature. American Journal of Infection Control, 44(5), e17-e21. Retrieved from


Chlorhexidine bathing is effective in reducing levels of pathogens on skin. In this review, we examine the evidence that chlorhexidine bathing can prevent colonization and infection with health care-associated pathogens and reduce dissemination to the environment and the hands of personnel. The importance of education and monitoring of compliance with bathing procedures is emphasized to optimize chlorhexidine bathing in our clinical practice.

Dunne, CP, Keinänen-Toivola, MM, Kahru, A, Teunissen, B, Olmez, H, Gouveia, I, Melo, L, Murzyn, K, Modic,M, Ahonen, M, Askew, P, Papadopoulos, T, Adlhart, C, Crijns, F. (2017) Anti-microbial coating innovations to prevent infectious diseases (AMiCI): Cost action ca15114. Bioengineered. 0:0, pages 1-7.


Assessing the costs of healthcare-associated infection (HAI) is challenging. Methodological issues abound. Previous estimates have been derived in diverse ways from varied perspectives in different settings with dissimilar data. Results can be confusing for all of us. Full societal costs, which are more inclusive than commonly reported direct hospital costs, have never been fully measured or reported. The enormous clinical and economic burden of infection places HAIs high on the list of devastating and costly illnesses, such as cancer, heart attack, stroke, and diabetes, thereby mandating further research and greater efforts to contain a pressing healthcare problem. This review is to think of other mechanisms we may able to develop for prevention of HAI’s.

Milstone, AM, Passaretti, CL, Perl, TM. 2008. Chlorhexidine: Expanding the Armamentarium for Infection Control and Prevention, Clinical Infectious Diseases, Volume 46, Issue 2, 274–281,


Health care-associated infections (HAIs) result in increased patient morbidity and utilization of additional health care resources. Rates of HAI are increasing despite advances in health care technology. Limited antimicrobial agents and a dry drug pipeline make unique prevention efforts critical. Chlorhexidine, an antiseptic solution that has been used worldwide since the 1950s, is a safe and effective product with broad antiseptic activity. New ways of using chlorhexidine-containing products are being implemented to promote antisepsis and prevent bacterial colonization and infection. We review some of the many infection control applications of chlorhexidine in the battle against HAI, such as general skin cleansing, skin decolonization, preoperative showering and bathing, vascular catheter site preparation, impregnated catheter site dressings, impregnated catheters, and oral decontamination. As mandatory public reporting and pay for performance force infection control issues to the forefront, we find that chlorhexidine-containing products may provide a vast armamentarium for the control and prevention of HAI.

Scheck McAlearney, A., Hefner, J.L., Robbins, J., Harrison, M.I. and Garman, A. (2015) Preventing Central Line-Associated Bloodstream Infections: A Qualitative Study of Management Practices. Infection Control and Hospital Epidemiology.


“Some of the variance associated with CLABSI prevention program outcomes may relate to specific management practices. Adding a management practice bundle may provide critical guidance to physicians, clinical managers, and hospital leaders as we work to prevent healthcare-associated infections” Scheck McAlearney et al (2015). Conclusion: A main theme that differentiated higher- from lower-performing hospitals was a distinctive framing of the goal of “getting to zero” infections. Although all sites reported this goal, at the higher-performing sites the goal was explicitly stated, widely embraced, and aggressively pursued; in contrast, at the lower-performing hospitals the goal was more of an aspiration and not embraced as part of the strategy to prevent infections. Five additional management practices were nearly exclusively present in the higher-performing hospitals: (1) top-level commitment, (2) physician-nurse alignment, (3) systematic education, (4) meaningful use of data, and (5) rewards and recognition. We present these strategies for prevention of healthcare associated infection as a management “bundle” with corresponding suggestions for implementation. Some of the variances associated with CLABSI prevention program outcomes may relate to specific management practices. Adding a management practice bundle may provide critical guidance to physicians, clinical managers, and hospital leaders as we work together to prevent healthcare-associated infections.

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