Review of literature related to prevention of nosocomial infection

REVIEW: CENTRAL LINE-ASSOCIATED BLOODSTREAM 2

REVIEW

CENTRAL LINE-ASSOCIATED BLOODSTREAM 2

Central Line-Associated Bloodstream Infections

Grand Canyon University

Translational Research and Evidence-Based Practice

DNP-820-O501

Running head: CENTRAL LINE-ASSOCIATED BLOODSTREAM 2

October 9, 2018

CLABSI Supporting Literature

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 CVCs, CLABSIs, risk factors, intervention, and benefits of preventive measures. Through inclusion and exclusion criteria many journal articles were 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.

Questions Posed in the Studies

Afonso, Blot, & Blot (2016) seeks to establish how hospital-acquired bloodstream infections can be prevented through the use of 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.

Education, Simulated Training, Experience, and Knowledge

Kadium (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? Other researchers that focus on how education, experience, and workshops enhance prevention or reduction of CVC infections include; El-Sol & Badawy, (2017), Leistner, Thürnagel, Schwab, Gastmeier, & Geffers (2013), and Soffle, Hayes, & Smith (2018). Dougherty (2014) 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.

Surveillance

Xu, & Wu, (2017), Commonwealth of Australia, (2015), Kadium, (2015), Morrison, Raffaele, & Brennaman, (2016), Tomar, Lodha, Das, Sood, Kapil, (2016), Lin, Apisarnthanarak, Jaggi, Harrington, Morikane, Thu, Ching, Villanueva, Zong, Jeong, & Lee (2015), and Esposito, Guillari & Angelillo (2017) concur with O’Grady, Alexander, Burns, Delilnger, Garland, Heard, Lipsett, Masur, Mermel, Pearson, Raad, Randolph, Rupp, & Saint (2015), the inquiry focused on how Positive blood culture shows the relationship between CLABSI and CDC surveillance.

Preventive Measures

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), Jones, Forsyth, Jenewein, Ray, DiMarco, Pugh (2017), Masse, Edmond, & Diekema (2018), Oliveira, Stipp, Silva, Frederico, & Duarte (2016). In 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).

Evidence-Based Practice

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 (2014), World Health Organization (WHO, 2018) and Xu & Wu (2017). Perin, Erdmann, Higashi, & Sasso, (2016)., Perin, Erdmann, Higashi, & Sasso, (2016), Tomilnson (2015),

Risk Factors

Taveira, Lima, Araújo, & Mello, (2016), Tomar, Lodha, Das, Sood, Kapil, (2016), Pepin, Thom, Sorkin, Leekha, Masnick, Peras, Pineleas, & Harris, (2015), Morrison, Raffaele & Brennaman, (2016) question the risk factors of CLABSI

Impact of Intervention

On the evidence-based impact of fighting CLABSI, there is an evaluation by Baldassarre, Finkelston, Decker, Lewis, & Niesley, (2014), and Scott II, Sinkowitz-Cochran, Wise, Baggs, & Goates, (2016).

Then there is Han, Liang, & Marschall, (2015), 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) examines the relationships between Positive blood culture and CLABSI.

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. Thorough knowledge on 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 healthcare, hence decreasing cases of infections.

Moreover, nurse experience is an essential subtopic due to evidence that supports that with higher experience in the CVC units; nurses tend to adhere and follow protocols and precautions which help prevent infections. Finally, there are Evidence-Based Practices/Interventions such as proper fitting, disinfection and sterilization, insertion 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., 2017). 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.

Other Risk factors

In a study conducted by Tomar, Lodha, Das, Sood, Kapil, (2016) among the common risk factors for central line infections are factors such as; triple lumen, changing of the central-line, and frequency of accessing the central line. However, avoiding unnecessary changing of the line, educated workers on hygiene and full barrier precautions, as well as ongoing surveillance through regular rounds helped to prevent infections. Of 265 enrolled children with a central line, 13 developed bloodstream infections (incidence density 5.03/1000 central-line days). In another research by Pepin et al. (2015), it is indicated that comorbidity conditions increase the risk for surgical site infections and the acquisition of antibiotic-resistant bacteria.

Additionally, Leistner, Thürnagel, Schwab, Gastmeier, & Geffers, (2015) indicate that when nurses in infant units are few infections rates are high. Taviera et al. (2016) purport that in children-based units, low white blood cell content, malnutrition, and CVC insertion before chemotherapy results in infections. Finally, Xu & Wu (2017) note that implantable ports SCS have the lowest risk while non-tunneled type had a very high risk. Among such factors and age, disease condition, gender (intrinsic factors) as well as prolonged hospital stay, multiple CVCs, CVC duration, internal jugular access, parental nutritional admission and insertion (extrinsic) CVCs are contaminated due to patient’s skin contact with organisms or direct contamination of catheter.

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 quickly 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. Unfamiliarity will occur at times, and the well-being of the patients is jeopardized (Stone et al., 2014). Just like any other profession, health care ties it’s 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 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 on preventing the cases of CLABSIs in hospitals is immeasurable. The same should be embraced and upheld.

Implementation of policy and surveillance

According to Namita et al., (2015) cooperation between nurses and the patient, e-learning, confidence offers better care for the CVC. Besides, checking pre and post-treatment axillary temperature, keeping the dressing closing, close monitoring of the patient, using aseptic technique, and maintaining CVC through anticoagulant as well as using polyurethane dressing with an external cloth border instead of polyvinylchloride catheter dressing reduce infection. In another study by Commonwealth of Australia, (2016) CLABSI surveillance has to offer a correct definition, blood culture, health-associated infection or HAI-non-inpatient and settings which are often; oncology, hematology, ICU, hospital-wide, high dependency units, and hemodialysis patient. Furthermore, the right timing, correct interpretation, and potential organisms should be established for surveillance to serve in reducing infections in CVC units. According to Tomlinson (2015) the study conducted on the effect of surveillance, in 6 months, the application of interventions right line, right time enhanced reduction on infections. Morrison, Raffaele & Brennaman (2016) to indicate that there is always improvement in service when nurses are given feedback on the CLABSI and risk factors. Out of 620 visually audited lines from 14 nursing units for 16 weeks, 113 lines did not audit. 628 risk factors were established. Through personalized nurse report cards infections decrease. Baldassarre et al. (2014) note when audit tools are used alongside education the compliance of nurses increases. Furthermore, Jones et al. (2017) state that repeated skill assessment enhances the safety of patients with CVC.

Education

El-Sol, A., & Badawy, A.I. (2017) studies how education module affects CABSI and indicates that most of the participants had a diploma in nursing and lacked proper practice for CVC. The pre-and post-education mean scores varied before and after training. It was established that knowledge, experience, and practice positively resulted in lower infections.

Other interventions

Aloushi, S.M. & Alsarai, F.A. (2018) opine that as long as the nurse-percent ration was lowered, the compliance in the patient’s outcome. Perin et al. (2016) postulate that hand hygiene and maximal barrier precautions; multidimensional programs and strategies such as impregnated catheters and bandages and the involvement of facilities in and commitment of staff to preventing infections.

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., 2015). 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 particular disease at a given period (Kim & Biorn, 2017). Reduced cases of 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.

Safe Costs While Making Profits

In one study by Scott II, Sinkowitz-Cochran, Wise, Baggs, & Goates, (2016) indicates that in a study on 40,556 and 75,067 central line-associated bloodstream infections were prevented in Medicare and Medicaid patients in critical care units in the period 1990-2008 with about $ 586-$862 million expenditure and control efforts that lead to saving $44–$131 with net profits of about 664 USD Million.

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 (ICU)?

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 CLABSIs infections in the past (Hsu et al., 2014). These two categories have a rich knowledge of 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 four articles were suitable for the study. Xu & Wu (2014) established 400 studies to establish the various types of catheters and the level of risk each gives. Similarly, Scott II, Sinkowits-Cochra, Wise, Baggs, & Goats (2016) utilized Medicare and Medicaid data from 1990-2008 to establish the cost saving after implementing preventive measures against CABSI. As for Perin et al. (2016), there was the use of 34 studies, but only 28 offered significant results in measuring CVC insertion and maintenance strategies. Soffle, Hayes, & Smith (2018) used a sample population of 20 traditional education and 78 for simulated-based teaching methods in establishing their efficiency in practical-based knowledge on prevention of CABSI. As for Namita et al., (2015) there was the use of 10 articles through which a deep study was done. In a study by Dougherty (2015), there was convenience sampling of a population of registered nurses in a long-term acute care hospital (LTACH) setting after completion of orientation to the unit. Out of 52 eligible nurses, 31 participated in the survey response. In Viana Taveira, Lima, De Araújo, & De Mello (2016) the sample included 188 children in pediatric cancer health care. While Leitine et al. (2016) put to use the very low birth weight (VLBW) newborns from NICUs who took part in the German nosocomial infection surveillance system for ventilated preterm infants from Jan 2008-2009. In a study by Elsol & Badawy (2017), there was convenience sampling with 44 nurses working in ICU who filled the questionnaire on demographic and CABSI related questions and observational checklist. For Aloushi & Alsarai (2018) is 171 ICU nurses in 15 hospitals within 15 hospitals in 5 cities of Jordan. The nurses were supposed to be registered, working as a full-time in the ICU; and with at least one year of experience. A panel of experts comprising members of 3 nursing faculties, two infection control specialists and 5 ICU nurses participated in the validation of the initial draft of the instrument, which contained 13 items. The mean age of the participants was 32.5 years; 32.7 for males, and 31.5 for females. Seventy-two participants (43%) had no previous education about CLABSI prevention guidelines, and 154 (90%) reported a lack of supplies in their hospital, such as antibiotic-impregnated central venous catheters. In the study by Morris et al. (2016), there was the utilization of 715 beds in the 2-campus acute care community hospital healthcare system in Southwest Florida.

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 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 comprehensive research in various facilities to establish methods of improving infection prevention and control on catheter units. Bianco et al. (2015) used samples from some 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 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 instructional interventional design among 60 registered dialysis nurses. Tomilnson (2015) focused on the population of inpatients who had peripheral IV therapy for 5-29 days within a 600-bed community hospital. Whereas Pepin et al. (2015) utilized patients aged 18 and more in the ICU with CVCs. Eligible participants had to have a central line for 48 hours and without prior CLABSI. In a study by Tomars et al. (2016), there was a study using children who stayed in PICU for more than 48 hours without infection at the time of admission. The study involved 265 children.

Other more studies include, 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 for 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., 2015). Also, the study by Basinger (2014) 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. Other researchers who complained of time that limited them from acquiring adequate and reliable data as well as having comprehensive studies include Kadium (2015), Pepin et al. (2015) Aloushi & Alsarai (2018). Therefore, it resulted in results that were not matching with the literature review and they could not be generalized on any other population 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. In other studies, location-based data was limited and focus on one type of catheter limited the generalization of results on every catheter (Perin et al., 2016).

Conclusions and Recommendations

Overall, there are various issues that are addressed in the various papers in this analysis. From the literature review, it is observed that fighting CABSI results in saving a lot of money that could be used by the healthcare in other projects (Scott, Sinkowitz-Cochran, Wise, Baggs, & Goates, 2016). 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. Similarly, Namita et al., (2015), besides, Viana Taviera et al., (2016) remind the health care practitioners on assessing other risks such as white blood cell content, malnutrition status, bone marrow aplasia, and CVC risks before chemotherapy because they increase the risks of infection among children. Thus, hospitals with high baseline hygienic standards of care and lower CLABSI rates might benefit less from chlorhexidine gluconate (CHG) washcloth bathing. Additionally, Lin et al. (2016) 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. (2015), 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.