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DNP 820 Topic 6 Benchmark Drafting a Literature Review DNP 820 Week 6 Benchmark Drafting a Literature Review DNP 820 Topic 6 Benchmark Drafting a Literature Review Details: In this assignment, you will draft the body of a literature review. You will continue to add and revise this draft literature review (Chapter 2 of your DPI Project) as you progress through the program. You may be able to use the feedback and suggestions from your instructor (on the Introduction to the Literature Review assignment in Topic 4) to expand the literature review for this assignment. General Requirements: Use the following information to ensure successful completion of the assignment: Use the “Empirical Research Checklist” worksheet to ensure that each article you select meets all of the established criteria. Use the “Research Article Chart” to provide a summary review of each component of your assignment. Submit the completed Research Article Chart to your instructor. Refer to the most recent prospectus template found in the DC Network (dc.gcu.edu) for details and criteria for the Literature Review (Chapter 2). Doctoral learners are required to use APA style for their writing assignments. The APA Style Guide is located in the Student Success Center. An abstract is not required. This assignment uses a rubric. Please Review the rubric prior to the beginning to become familiar with the expectations for successful completion. You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center. Directions: Part 1: Selection of 15 Articles   Select 15 empirical articles related to your PICOT question. Use the “Empirical Research Checklist” worksheet to ensure that each article you select meets all of the established criteria. At least one article must demonstrate a quantitative methodology. Part 2: Research Article Chart  Using the articles acquired in Part 1, provide a summary review of   CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS 2   CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS 16   Central Line-Associated Bloodstream Infections Literature Review   Kerry S. Murphy   Grand Canyon University   Translational Research and Evidence-Based Practice   DNP-820-O501   Dr. Kari Lane   September 26, 2018   Running head: CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS 1   Central Line-Associated Bloodstream Infections Literature Review   Central Line-Associated Bloodstream Infection (CLABSIs) in a fatal infection that results from bacteria or viruses entering the bloodstream through the central line. A central line, also known as a central venous catheter (CVC), refers to a tube used by doctors to administer medication, fluids or to collect blood from the body of a patient (Deason & Gray, 2018). Central Line-Associated Bloodstream Infection is one of the leading causes of deaths each year in different countries across the globe. Central Line-Associated Bloodstream Infection has been an area of interest for many healthcare researchers representing a diverse body of knowledge about the infection while still expanding on what is already known. The paper is an analysis of articles related to CLABSIs with the major themes of concern to the authors including risk factors, interventions, CLABSIs and Hospital Acquired Infections (HAIs), benefits of the preventive measures and the common symptoms of CLABSIs. There were 200 articles that were established to talk about the CVCscatheter, CLABSIs, risk factors, intervention, and benefits of preventive measures. Through inclusion and exclusion criteria many journal articles , wereere left out because of being written in other languages rather than English. Therefore, the use of the English language index the Cumulative Index of Nursing and Allied Health Literature (CINAHL) was used to search related ,journal articles. Other search tools include The National Center for Biotechnology Information (NCBI) – PubMed. Studies older than five years were excluded to ensure that the research remained current and up to date. Using real-time cases or conditions helps to improve the quality and validity of the resulted research. having done years ranging from 2012 and backwards, and lacking openness to the public. Therefore, 29 were used in the study. Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: DNP 820 Topic 6 Benchmark Drafting a Literature Review Questions Posed in the Studies   Afonso, Blot, & Blot (2016) seeks to establish how hospital-acquired bloodstream infections can be prevented through the use of DNP 820 Topic 6 Benchmark Drafting a Literature Review chlorhexidine gluconate-impregnated washcloth bathing in intensive care units. In the study by Chidambaram (2015), the question raised is, what associations dental procedure and CVCs have. Kadium, M. (2015) inquired into how the education program for one month, based on the evidence-based guidelines recommended by CDC, will improve registered dialysis nurses’ knowledge regarding CVC maintenance care? Dougherty (20142) questions the potential solutions in reducing incidences of central-line associated bloodstream infections have to be created in line with the clinical setting and careful consideration of the patients and the organizational culture. Lin, Apisarnthanarak, Jaggi, Harrington, Morikane, Thu, Ching, Villanueva, Zong, Jeong, & Lee , (2015), and Esposito, Guillari & Angelillo (2017) concur..   O’Grady, Alexander, Burns, Delilnger, Garland, Heard, Lipsett, Masur, Mermel, Pearson, Raad, Randolph, Rupp, & Saint (20151), the inquiry focused into how Positive blood culture shows the relationship between CLABSI and CDC surveillance. Other researchers inquire into the CLABSI-related preventive measures implemented among adult patients hospitalized in an ICU. Such studies are by people like Perin, Erdmann, Higashi, Sasso, Bianco, et al. (2016), Masse, Edmond, & Diekema (2018), Oliveira, Stipp, Silva, Frederico, & Duarte (2016). In a research by Basinger, (2014), the research question questions into the causal effects of the Comprehensive Unit-based Safety Programs (CUSP) on the reduction of CLABSIs within the relationship CUSP team member webinar attendance has with the reduction of CLASBIs. Other questions were on how knowledge and education of the family and patient could help in the prevention of CLABSIs attack. Among such studies are; Kadium, (2015) and Powell (2018).   Other studies focused on how evidence-based practice, insertion, and maintenance of CVC could protect the patients from CLABSIs. Such research was done by Bianco, Coscarelli, Nobile, Pileggi, & Pavia (20143), WHO (2018) and Xu & Wu (2017). The final research is by Han, Liang, & Marschall, (20150), who question how the involvement of education to the family and the patient can help prevent CLABSIs attacks among patients on CVC care. Another study by Yazan & Regunath (2018) questions examines the relationships between Positive blood culture and CLABSI with CDC.   Identified Subthemes   From this, there are various subthemes that emerge in this study. These include; Hygiene and impact of this on the CVC situation. Most studies show that the more hygiene is considered and practiced, the lower the cases of CLABSI. Another concept is the knowledge that is necessary among nurses and patients handling CVC. Through knowledge m the care for CVC improves and infections reduce. Besides, there are Policies which enhance the correct application of knowledge and maintenance of hygiene in the health care, hence decreasreducing cases of infections.   Moreover, nurse experience is an essential subtopic for due to evidence that supports that with higher experience in the CVC wardsunits;, nurses tend to takeadhere and follow ptoticls and precautions and which help prevent infections that those without. Finally, there are Eevidence- Based Practices/Interventions such as proper fitting, disinfection and sterilization, iInsertion bundle, maintenance bundle, and quality improvement.   The reviewed literature has shown that the nurse, patients, family, and evidence versus non-evidence-based practice are important in the analysis of the situation. Besides, the setting, the type of catheter, and conditions affect the entire discussion.   Risk Factors Associated with CLABSIs   a. Contamination on Insertion   The catheter may gain entry into the bloodstream during the insertion of the line into the body of the patient. The rate of infections during insertion is substantially dependent on the hygiene levels that are put in place by the health care providers (Dick et al., 2015). The rates of infection during insertion happen to be high showing ignorance or lack of professionalism among the health caregivers. Contamination during insertion may also result from the instruments used and how sterilized they are.   b. Contaminated Skin of the Patient   The insertion is done on the body of the patient. A contaminated skin of the patient may contain germs which may enter the body during the insertion (Dombecki et al., 2017). The fact that patients have negligible knowledge concerning the different ways the infection may occur means that there is so much responsibility placed on the health caregivers. The infection rates due to unsanitary practices of the patients seem to have drawn the attention of the authors of the different articles analyzed. With the rates of CLABSIs rising each year, mortality rates have also increased. Researchers have made CLABSIs prevention a priority to address such risk factors to avoid or reduce infection rates.   c. Non-Compliance with the Central Line Maintenance   There are guidelines for healthcare professionals meant to reduce the chances of CLABSIs infection. Such guidelines include not using antiseptics and ensuring complete dressing changes (Orwoll et al., 2018). As much as these guidelines and policies are in place does not mean that compliance is definite. Cases of caregivers who do not comply with the stipulated guidelines are common and such levels of unprofessionalism have cost patients their lives.   Interventions   a. Removal of Unnecessary Lines   The authors agree that there are times patients will have lines which are no longer being used for any medical purpose. These are mainly patients who have spent so much time in the hospitals, and the chances of being discharged seem minimal (Sodek, 2016). The caregivers are meant to remove lines once they have served the purpose. The more these lines remain on the body of the patients the more the chances of infection. Bacteria and all other associated germs will easily enter the body.   b. Health Care Providers to Follow Recommendations   Healthcare professionals are trained on the best practices that are meant to ensure that the chances of patient infections are minimized or even eliminated entirely. Unfamiliarity creeps in at times, and the well-being of the patients is jeopardized (Stone et al., 2014). Just like any other profession, health care ties the professionals around practices which ensure ethical undertakings to safeguard the lives of the patients. The authors are for the idea that health care professionals should be just to patients and do what their work ethics dictates them to do. Such will ensure improved health and safety of the patients.   c. Encouraging Teamwork   In any health care setting, there are two main participants. These are the health caregivers and the patients. One of the authors suggests that teamwork between these two parties will go a long way in reducing the rates of these infections (Stone et al., 2014). Teamwork will ensure that there is knowledge sharing, that key concerns and risks that may be known to one of the parties are made known to the other. The impact teamwork will have ontowards preventing the cases of CLABSIs in hospitals is immeasurable. The same should be embraced and upheld.   CLABSIs associated infections/Transmissions   a. Hematogenous Transmission   This is an infection that is characterized by a primary tumor penetrating into blood vessels. They then get transported in the blood vessels and eventually into the distant parts of the body of the patient (Stone et al., 2014). Once at the distant sites, the cells will penetrate the walls of the vessels again and build a basis for another, a new tumor on the new site. Such are the same cases that happen with CLABSIs. Examples include catheter-associated Urinary Tract Infections (CAUTI) that can lead to CLABSI’s.   b. Catheter-associated Urinary Tract Infections (CAUTI)   A urinary tract infection (UTI) refers to an infection in any part of the urinary system. UTIs are also common healthcare-associated infections reported by both patients and healthcare givers. These infections are associated with urinary catheters, a tube which is used by doctors through the urethra to drain urine (Douglas, 2015). Most of the hospitalized patients end up with urinary catheters inserted in their bladder. Prolonged use of the catheters increases the risks of the infections. Health caregivers should ensure that these catheters are removed when not being used to reduce the risk of patients contracting the CLABSIs.   c. Contaminated Infusates   The term refers to the introduction of pathogens into the body of patients. The introduction of these pathogens occurs through the sterile used by the health care providers. During surgery or during other procedures which may require line insertion, bacteria may be introduced into the body of the patient (Stone et al., 2014). Contaminated infuscate happen to be one of the ways CLABSIs bacteria is introduced into the bloodstream. Patients and the health care providers need to be educated on such risks.   Necessity for Interventions   a. Reduced incidences of CLABSIs   The preventive measures mentioned above by the authors of the different articles will go a long way into reducing the incidents that are reported by patients and caregivers concerning CLABSIs (Klintworth et al., 2014). Encouraging adherence to the hygiene standards, the policies and the recommendations as they relate to CLABSIs infections will enable the creation of an environment that will enhance the well-being of the patients and also minimize the chances of contraction of the infections. The infection is deadly and is already costing patients and nations dearly.   b. Reduced morbidity   Morbidity has been defined as how often a disease occurs or is reported in a population. The morbidity rate is determined by examining the number of patients with a certain disease at a given period (Kim & Biorn, 2017). Reduced cases of a disease mean that preventive and treatment measures are effectively implemented by all stakeholders involved. CLABSIs infections are no exceptions here. The literature work of the previous authors appreciates that the health care institutions that have adopted the interventions measures above report few and reduced cases of the infection.   CLABSIs Symptoms   a. Site Discharge   The area where the catheter is placed should remain dry, and no discharge should be coming from the area. Some patients, however, may notice yellow or green discharge (Conley et al., 2018). The drainage should be a cause for alarm, and the authors have identified the discharges as some of the top indicators that something has gone wrong and healthcare providers should act up. Discharges show that the area is not fresh and has been exposed to bacteria and germs, something that should be of great concern.   b. Site Swelling   Patients may experience additional swelling at the place where the catheter line has been inserted. The swelling is an indicator that there is no healing that is taking place and that there is every reason to worry about the well-being of the patient (Castagna et al., 2016). The authors suggest that nurses should give attention to the recovery process of patients and ensure that such instances are noted and addressed. In cases where there is no close relationship between the health caregivers and the patients, such incidents may be hard to notice, and the patients end up suffering and worse still, be exposed to the ugly infection which may even cost them their lives.   c. Site Redness   A patient may develop red streaks at the area where the line has been inserted. Another warning sign that the patient may be headed to a CLABSIs. Again, if there is no close interaction between patients and their caregivers such may be hard to notice (Chesshyre et al., 2015). Worse still if the patient is not aware that such are causes for alarm. They may never report the same and end up risking their lives. Adult patients and children are at the greatest risk of these symptoms because in most cases they do not know what should be made known to the health care providers and what should not be a cause for worry.   Research Questions   a. How does the training of health-care providers on the risks and the preventive measures of CLABSIs impact the overall infection rates?   b. What is the level of knowledge of nurses regarding the use of evidence-based guidelines to prevent central venous catheter bloodstream infections?   c. Does an increase in nurse’s knowledge concerning CLABSIs infections reduce the number of infections in the Intensive Care Units?   Sample Populations   The authors have utilized different study populations to accomplish their objectives. The two major categories of respondents that are common to all authors are healthcare professionals and adult patients suffering from or who have suffered the CLABSIs infections in the past (Hsu et al., 2014). These two categories have a rich knowledge ofn the study topic. Such enables researchers to collect adequate data for their research topics and also draw logical conclusions.   There are several processes through which people sample information in studies. For Alfonso et al. (2016) the search of the various database using key terms gave 291 records, however, based on relevance only 4 articles were suitable for the study. In a study by Dougherty, there was convenience sampling of a population of registered nurses in the LTACH setting after completion of orientation to the unit. Out of 52 eligible nurses, 31 participated in the survey response.   The study by Lin et al (2015) utilized a cross-sectional design in the qualitative analysis of sources based on the key concepts of the study. Perin et al. (2016) explored a purposive sampling and selection of 34 studies that formed a set through which to assess results after a systematic review of academic and health database. In the sampling process, Esposito (2017) utilized a cross-sectional design in 16 non-teaching and teaching public and private hospitals with units utilizing CVCs for adult oncological patients. The target group was 472 nurses in the oncology and outpatient chemotherapy units of the selected hospitals.   Likewise, Oliveria et al (2016) samples were collected through a cross-sectional study with questionnaires to 76 professionals in the intensive care. Zu & Wu (2017) utilized the qualitative process and a systematic search of databased on CINAHL, ABI INFORM, and OVID through which they established more than a hundred articles before applying the exclusion-inclusion criteria and utilizing ten articles in the study. WHO (2018) held a comprehensive research in various facilities to establish methods of improving infection prevention and control on catheter units.. Bianco et al. (20153) used samples from a number of CLABSIs which were collected by the hospital-based IP in line with the NHAN approach and definition of CLABIs. The CUSP teams of hospitals receive monthly feedback on infections and quarterly feedback on rates of infection per 1,000 catheter days. Basinger (2016) samples were collected through a cross-sectional study with questionnaires to 76 professionals of varied gender, and ages in the intensive care. In another study by Chidambaram (2015) the samples used were acquired from existent studies. On the other hand, Kadium (2015) utilized a convenience sampling of registered dialysis nurses in the hemodialysis unit was used in a pre and post-test educational interventional design among 60 registered dialysis nurses. Powell (2018) investigated information from 20 patients, three of whom were children and the rest adults. Masse, Edmond, & Diekema (2018) surveyed information from a literature review of studies ranging from 2008 to data to establish the infection prevention approaches performed outside the operating room. In most of the studies, the aspects of age, gender, and marital status were never necessary forin the study. The focus was on the usage of the CVCs.   Limitations   There are several obvious limitations in the studies. For example, Esposito et al. (2017) opine that self-reported questionnaires affected accuracy in response, most respondents gave information that was positive rather than genitive on hygienic consideration of CVCs. Questionnaires ought to be anonymous to encourage correct reporting. He also notes that a cross-sectional study hindered establishing a causative relationship with outcomes of interest. Future studies need to focus on non-evidence-based practices and dressing of catheters and how they relate with CLABSI (Han et al., 20153). Also, the study by Basinger (20144) was limited by failure to separate the efforts that aim at improving the use of CUSP, related approaches, and technologies that reduce compliance in hygiene situations of CVC.   In the study by Afonso et al. (2015) the limitation was in the use of cumulative analysis on line-associated HABSI types while reporting the catheter culture is a diagnosis of infection lead to difficulties in isolating categorical data on attitudes, knowledge, and practical application of knowledge. Moreover, another study by Lin et al. (2015) showed that the limited time and consideration of barrier towards quality, an aspect that needed adequate time hindered acquisition of enough information. Furthermore, Perin et al. (2016) note that the use of one type of catheter hindered generalization of information to other health departments.   Chidambaram (2015) assert that there was limited evidence as a result of the utilization of the exploratory method when conducting a study on CLABSIs hence a lot of data never emerged clearly. According to Kadium (2015) the small sample size and short duration within which it was conducted limited the results that were acquired. Another problem emerged because there was no assessment of the learning styles of the patients. According to Powell (2018), some electronically captured information gave collinearity that challenged in the interpretation of results.   The Conclusions and Rrecommendations   Overall, there are various issues that are addressed in the various papers in this analysis. From the literature review, Afonso et al. (2016) conclude that hospitals achieve zero infections of CLABSI rates meaning the continued usage of surveillance together with a washcloth bathing for they curtail Gram-positive bacteria. Thus, hospitals with high baseline hygienic standards of care and lower CLABSI rates might benefit less from CHG washcloth bathing. Additionally, Lin et al. (2015) note that the adherence to the current evidence-based practice guidelines, education, and consideration or compliance to hygiene, and use of chlorhexidine antiseptic bathing instead of the soap helps in the prevention of CLABSIs. For example, according to O’Grady et al. (20151), maximal sterile, cautious insertion of catheters, avoidance of routine catheter replacement, usage of the antiseptic/antibiotic impregnated short-term central venous catheters and chlorhexidine-impregnated sponge dressings help to prevent and manage CLABSIs.   Similarly, Perin et al., (2016) opine that the consideration of necessary interventions on the catheters can prevent infections. According to Esposito et al. (2017) in situations where nurses have a positive attitude, and perceive hygiene as a risk in CLABSIs as well as where evidence-based practice programs are used, infection is likely to be prevented. There is still a low adherence to handwashing. Xu & Wu (2017) note that patient cooperation and knowledge of proper care for CVC prevent infections. There is a need for studying practical clinical nurse interventions in the care for CVC. In the study by Han et al (20153) state that blood culture is necessary for managing CVC patients. Formal training, years of experience, written policies, enhance compliance withto proper CVC care and reduce infections (Han et al., 20153). In a study by Bianco et al. (20153), there is a conclusion that less costly evidence-based education, CUSP prevent infections. It is also indicated that multidisciplinary education programs improve assistance to patients (Oliveira et al., 2016)   According to Afonso et al. (2016), an analysis into the topic requires separate primary, secondary and central line-associated HABSI types in reporting catheter culture during the diagnosis of bloodstream infection that increases certainty and lowering of risks of bias as a result of improper attribution of blood culture contaminants.   Furthermore, Powell (2018) notes that if hospitals use surveillance for antimicrobial use and resistance options in ambulatory surgery, and acute care hospitals, then infections will be eliminated. In the study by Chidambaram (2015), the conclusive view offers that the dental care process is necessary for pediatric CKD patients if studies on CVC are being held. Besides, CVC benefits CKD patients but poses a threat for long-term candidates due to negligence on disinfection and sterilization processes. According to Kadium (2015), high education levels do not affect pretest, but the completion of infection control course affects pretest scores. Another argument is that evidence-based care allows students to work purposefully. Moreover, the provision of continuous education enhanced retention and application of knowledge in tasks. In another study by Masse, Edmond, & Diekema (2018) as expert opinion high-quality evidence practice through sufficient evidence via trainings and assessment result in proper care for patients with catheters. Ultimately, WHO (2018) suggests that as long as a health care establishes a comprehensive action plan, assessment baseline, execution, checks the impact and establishes a sustainable long-termn plan, CLABSI cases can be prevented. It is thus necessary for future studies to focus on more than one type of catheter for results to be relevant to various departments of health.   From the above literature review, it is clear that evidence-based practice, policies, hygiene, education and attendance of workshops are important aspects that need to be studied. Besides, the consideration of the study population, using the adequate time for the study, having confidential questionnaires are part of the essentials of conducting a useful study on CVCs and CLABSI’s.   The conclusions and recommendations are drawn from what the authors had from their results. There is the need for continued monitoring and feedback concerning compliance with the set hygiene practices aimed at preventing CLABSIs infections. The infection basics, such as patient and health care providers’ education, should be addressed (Beverly et al., 2018). Public health funding has also been suggested as a recommendation towards the prevention of the infection. Further areas of the study should address different ways of tracking infections, whether they are high at the emergency rooms or the operation rooms. The areas for further research should also focus on strategies aimed at removing barriers in policies and practices.   References   Afonso, E., Blot, K., & Blot, S. (2016). Prevention of hospital-acquired bloodstream infections through chlorhexidine gluconate-impregnated washcloth bathing in intensive care units: A systematic review and meta-analysis of randomizsed crossover trials. Eurosurveillance, 21(46). doi:10.2807/1560-7917.es.2016.21.46.30400   Basinger, M. A. (2014). The Reduction of Central Line-Associated Bloodstream Infections in Intensive Care Units through the Implementation of the Comprehensive Unit-Based Safety Program. Retrieved from m https://digitalscholarship.unlv.edu/thesesdissertations/2057/   Beverly, A. L., Hill, M. M., Camins, B. C., & Lee, R. A. (2018). Decreasing CLABSI incidence associated with decreasing MRSA Bacteremia LabID Incidence. American Journal of Infection Control, 46(6), S82.   Bianco, A., Coscarelli, P., Nobile, C. G., Pileggi, C., & Pavia, M. (2014). The reduction of risk in central line-associated bloodstream infections: Knowledge, attitudes, and evidence-based practices in health care workers. American Journal of Infection Control, 41(2), 107-112. doi:10.1016/j.ajic.2012.02.038 Comment by Microsoft Office User: Delete this reference and update with a reference that will be within 5 years of age based on your anticipated graduation date   Castagna, H. M. F., Kawagoe, J. Y., Gonçalves, P., Menezes, F. G., Toniolo, A. R., Silva, C. V., … & Correa, L. (2016). Active surveillance and safety organizational goals to reduce central line-associated bloodstream infections outside the intensive care unit: 9 years of experience. American journal of infection control, 44(9), 1058-1060.   Chesshyre, E., Goff, Z., Bowen, A., & Carapetis, J. (2015). The prevention, diagnosis, and management of central venous line infections in children. Journal of Infection, 71, S59-S75.   Chidambaram, R.(2015). A cautionary tale on the Central Venous Catheter: medical note for oral physicians. The Malaysian Journal of Medical Sciences, 22(5), 78-84.   Conley, S. B., Buckley, P., Magarace, L., Hsieh, C., & Pedulla, L. V. (2017). Standardizing best nursing practice for implanted ports. Journal of Infusion Nursing, 40(3), 165-174.   Deason, S., & Gray, P. (2018). Beyond the walls: infection prevention expands to the outpatient environment. American Journal of Infection Control, 46(6), S82.   Dick, A. W., Perencevich, E. N., Pogorzelska-Maziarz, M., Zwanziger, J., Larson, E. L., & Stone, P. W. (2015). A decade of investment in infection prevention: a cost-effectiveness analysis. American journal of infection control, 43(1), 4-9.   Dombecki, C., Vercher, J., Valyko, A., Mills, J., & Washer, L. (2017). Implementation of a Central Line-associated Bloodstream Infection (CLABSI). Prevention bundle for adult hematologic malignancy and bone marrow transplant patients. American Journal of Infection Control, 45(6), S103.   Douglas, M. (2015). 25. The journey to zero CLABSI: Impact of unit-based CLABSI prevention program. 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D., & Marsteller, J. A. (2014). Impact of self-reported guideline compliance: bloodstream infection prevention in a national collaborative. American journal of infection control, 42(10), S191-S196.   Kadium, M. (2015). Improving Nurses’ Knowledge to Reduce Catheter-Related Bloodstream Infection in Hemodialysis unit. Walden Dissertations and Doctoral Studies, 1-133.   Kim, R., & Biorn, J. (2017). Healthcare-Associated Clostridium difficile Infection Solution Guide. American Journal of Infection Control, 45(6), S103.   Klintworth, G., Stafford, J., O’connor, M., Leong, T., Hamley, L., Watson, K.,& Worth, L. J. (2014). Beyond the intensive care unit bundle: Implementation of a successful hospital-wide initiative to reduce central line-associated bloodstream infections. American journal of infection control, 42(6), 685-687.   Lin, M.L., Apisarnthanarak, A., Jaggi, N., Harrington, G., Morikane, K., Thu, T.A., Ching, P.Villanueva, V., Zhiyong Zong, Jeong, J.S. & Lee, C. (2015). APSIC guide for prevention of Central Line-Associated Bloodstream Infections (CLABSI) 5(16). https://doi.org/10.1186/s13756-016-0116-5   Masse, V., Edmond, M.B., & Diekema, D.J. (2018). Infection prevention strategies for procedures performed outside operating rooms: A conceptual integrated model. American Journal of Infection Control. 46 (2018) 94-6. Retrieved from https://www.ajicjournal.org/article/S0196-6553(17)30947-1/pdf   O’Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., … Saint, S. (2015). Summary of Recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections. Clinical Infectious Diseases, 52(9), 1087-1099. doi:10.1093/cid/cir138   Oliveira, F. T., Stipp, M. A., Silva, L. D., Frederico, M., & Duarte, S. D. (2016). Behavior of the multidisciplinary team about Bundle of Central Venous Catheter in Intensive Care. Escola Anna Nery – Revista de Enfermagem, 20(1). doi:10.5935/1414-8145.20160008   O’Neil, C. B. 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