1.

Introduction

There is a higher rate of infection associated with the catheter. But not all nurses and patients

know that central venous catheter can cause serious consequences such as low motility and

morbidity Bloodstream's central line-associated infections. We understand that when it

happens, it takes a long time to treat the infection. The patient's life will be at risk if the disease

gets worse (Frasca, Dahyot-Fizelier, & Mimoz, 2010).

We believe that prevention is better than cure. The focus of this study is therefore on

prevention of complications and how to educate patients about treatment with CVC. The

patient's nurse, doctor and family is a team. They need to work together to achieve a better

treatment result. The study also aims to make nurses conscious of the catheter-related disease

( Xu & Wu , 2017).

The approach we can use is a literature study. We were gathering data and analyzing the data.

Finally, we found 10 papers we used to look into in detail According to our research questions

and clinical report, there are a number of nursing strategies that we can do to stop CVC

infection. Patient education needs not only the support of the patient, but also the nurse ( Xu

& Wu , 2017).

The most severe consequence of catheter infection is called CLABSIs for nurses who will identify

the signs and symptoms of infection. It is a primary indicator of the quality of critical nursing

and ICU. The risk of CLABSI increases in addition to the length of the catheter, that also includes

the risk of increased morbidity and mortality. (Zingg, Cartier-Fässler & Walder 2008, 410).
Our research aims at providing deeper insight into CVC treatment and letting nurses know the

importance of preventing infection with catheters. We hope that people can get to know CVC

more. We won't feel odd to this machine if we face the situation in case and fear the operation.

2. Prevention of Infection: Nursing Interventions

In establishing recommendations for disease control, the World Health Organization (WHO) and

the Center for Disease Control and Prevention (CDC) are involved. In recent years, health-

related bloodstream infections (HABIS) have increased. The cost of these infections is high,

both in financial expense and morbidity of infectious diseases. The avoidance of sickness is

taken into consideration.

The CDC provides timely recommendations on many of the situations a nurse may face when

taking care of patients or teaching them how to prevent hospital infection. And it can be

divided into many parts to prevent infection. Isolation precautions are the basic safeguard for

infection prevention, which are guidelines designed to prevent microorganism transmission in

hospitals.

In this section, we strive to do security nursing, provide patient treatment, while at the same ti

me protecting patient safety as well as ourselves (2015 Calfee).

METHODS

Protocol and Registration

To ensure maximum transparency of research projects, the protocol was registered in the Inter

national Prospective Register of Systematic Analysis (PROSPERO) registry.In methodology

section we explain the scientific method used in this chapter to describe the process of

working. Methodology will help readers to understand the reliability of the results. Some

difficulties always arise while writing methodology . It needs a good structure and format. We

need to strike a balance between all the relevant information and keep the section short and

precise (Shuttleworth, 2009).

In this review we followed recommendations from the Cochrane Effective Practice and Care

Review Group Organization (EPOC) to evaluate quality (Jackie; Churchill, Rachel; Higgins, Julian;

Lasserson, Toby; Tovey, David;).Based on the Grades of Recommendations, Assessment,

Development and Evaluation (GRADE) Working Group, the quality of evidence for each included

study was determined (Schünemann et al., 2011). Only studies have been included with

moderate to high quality ratings.

Table. Definition of grades of recommendations (NHMRC 2009) (Gopalakrishna, 2013)

Grade of Recommendation Description

A Body of evidence can be trusted to guide practice

B Body of evidence provides moderate support to guide practice

in most situation
C Body of evidence provide limited support for recommendation

and care should be taken in in its application

D Body of evidence is weak and any recommendation must be

applied with caution

E Body of evidence is insufficient to provide reccommendation

2.1. Literature Review

An overview of a selected topic and sources is the literature review. Reviewable sources include

magazines, books, articles, etc. The literature review's aim is to provide an overview of the

topic chosen. In previous studies, it can identify new definitions and expose any holes. The

study of literature helps to illustrate the further course of research. There are 4 steps in the

literature review process.

Phase 1 needs to make a decision on your subject and the review's scope.

Stage 2 is looking for relevant data servers.

Step 3 is to read and review the sources and decide whether they are relevant to your subject.

Step 4 analyzes the selected sources, discusses them and explains them, then gives the

conclusion based on your analysis(Concordia 2017.)

About care and prevention of infection of CVC, there is upside potential in this field of nursing.
The literature review aimed to classify studies published between 2005 and 20019 using the PIC

O model (Leslie and Finn, 2003).

2.2. Study selection and appraisal

A four-stage selection process with independent reviewers at all stages was used to

classify relevant studies. Disagreement was settled by consensus or, if necessary, by an indepen

dent third party adjudication. (levett, 2019)

Firstly, we selected the papers with abstract in full text and published no more than 10 years

ago. Titles and abstracts are reviewed on the basis of criterion for inclusion / exclusion. Each

author independently analyzed the titles and abstracts of all the electronically screened and

selected papers. In the case of a short or ambiguous argument, the complete text was read for

evaluation. The reasons for discarding studies among the screened are noted. Based on the full

text, the remaining studies are reviewed for eligibility. Authors have been asked for copies of

posters or slides for conference proceedings. These were updated at the full-text level where

available; where not, the inclusion was based on the abstract alone. (Waffenschmidt, Hausner,

Sieben, Jaschinski, Knelangen, & Overesch,

2018).For any other relevant studies, reference lists from existing systematic reviews and recen

tly published recommendations for central venous line from the WHO and central venous

line are reviewed in the third phase. Finally, further analysis of the data was

applied during data extraction; reports using the same data set and reporting identical results a

re de-duplicated, including the latest or most full article (levett, 2019).

 2.3. Inclusion and exclusion Criteria

The researcher may determine whether or not the sources are applicable to the research topic

by using the inclusion and exclusion criterion. Criteria for inclusion and exclusion should be

established clearly and appropriately to avoid confounding authors with irrelevant data.

Inclusion and exclusion requirements should be clearly and reasonably defined to avoid

confusion between writers .The box below contains all the criteria for inclusion and exclusion.

TABLE.1 The criterion for inclusion and exclusion

Inclusion criteria Exclusion criteria

Studies published between 2005 and 2019 Research articles published prior to

2005

Peer-review journal articles, academic research Non-academic researches, conference

articles. abstracts, oral presentation or not

original research articles.

Studies with clear aim, methodology or data Studies with unclear aim, methodology

collection or clear description of intervention applied. or data collection or no clear

description of intervention applied.

Central venous catheter research articles: treatment a Articles of work not on central venous

nd prevention of infection catheter: treatment and prevention of

infection

Research articles on the perspectives of nursing Research articles are not in the context
 of nursing

Articles of research are available in English Research articles are not available in

English

Research articles with description in the keywords are Research articles with abstract in the

available in full text key words are not available in full text

Study papers from repositories of the Centria library Research papers from the collections o

f the Centria library

Table of Excluded studies

Author/Year Title Reason of Exclusion

2.4. Search Strategy

MEDLINE; CINAHL Plus; EMBASE; PubMed; Cochrane Library, Google Scholar and Scopus

databases were searched using the following keywords (or abbreviations) and MeSH search

terms; (Central venous catheter and nursing education), (Central venous catheter and prevent

infection), (Central venous catheter and care) and (Central venous catheter and nursing

interventions).

Table : NHMRC Designations of Levels of Evidence

Level Intervention No. Of Papers

Identified

I A systematic review of level II

II A randomized controlled trial

III-1 A pseudorandomised controlled trial (i.e. alternate allocation

or some other method)
III-2 A comparative study with concurrent controls:
• Non-randomised, experimental trial
• Cohort study
• Case-control study
• Interrupted time series with a control group
III-3 A comparative study without concurrent controls:
• Historical control study
• Two or more single arm study
• Interrupted time series without a parallel control group
IV Case series with either post-test or pre-test/post-test
outcomes
GPG GPG Guidelines from international organization

2.5. Data Collection

Collecting data assists in checking, arranging, converting, incorporating and extracting informati

on. To eensure that all details are reliable and complete, the system must be strictly recorded.

It is a tool that can systematically collect and quantify variable data.

This then helps the researchers to answer questions and interpret the results. Data collection is

a field we use to preserve learning's credibility. (2015 Tartu Ulikool).

For data entry and management, the Cochrane Collaboration RevMan program (Cochrane Colla

boration, 2014) was used.

The data were collected after the manual checklist of the Cochrane (Higgins and Green, 2011).
We selected the papers that were available in full text with abstract and posted not more than

10 years ago, according to the inclusion and exclusion criteria. We selected all the reports writt

en in English because of the language barrier.

At the beginning, while we were preparing the study and we used key words like prevention dis

ease, central venous catheter, and nursing intervention before we did the actual search to get a

general overview of the 18 tests.

In the final research, we used the following terms: (Central venous catheter and nursing

education), (Central venous catheter and prevent infection), (Central venous catheter and care)

and (Central venous catheter and nursing interventions). Since there have been more than

hundreds of articles, we are reading the titles and abstracts to reduce the number of articles

based on our inclusion and exclusion criteria. Then we read the articles, the introduction, the

conclusion, and some chapters. We finally selected 10 articles related to our field of study.

TABLE 2. Initial results of search

Search terms CINAHL ABI INFORM OVID

Central venous catheter and education for nursing 22 49 1606

Central venous catheter and disease prevention 72 20 808

Central venous catheter and care 326 3174 54

Central venous catheter and nursing interventions 27 348 6

2.6. Outcome Measures

Following suggestions from the Cochrane EPOC Review Group (Chandler et al., 2013), the follow

ing outcome variables were accessed.

2.7. Primary Outcomes

Identification and incidence of Rate of systemic central venous line associated infection and

causative agents.

2.8. Secondary outcomes

 The studies examined a variety of interventions, including

 education based interventions

 skill-mix based interventions

 equipment based interventions

 various dressings and aseptic based interventions .

 evaluation of the use of the different central venous line insertion bundles including the

Institute for Healthcare Improvement (IHI) bundle

2.9. Data Extraction Process

After piloting, a specifically developed Microsoft Excel data collection form was used to extract

the following information, and study design from each study: characteristics of the research

(name of the study, authors, year of publication, paper, location of the study, length of the

follow-up, time of infection and number of participants and incidents), characteristics of nurses

(age and gender, education, level of expertise), method of intervention and intervention

evaluation, reproducibility and validity of the study. A sensitivity analysis excluding studies
judged as low-quality was conducted for the primary outcomes.

To assess the quality of included studies, we derived a score summarizing 15 aspects of each sa

mple, including study design, response rate, followup rate, followup time, measures of exposur

e and outcome, and statistical analysis.

3.7. Statistical Analysis

No.of researchers used the Meta-

Analysis of Statistics Assessment and Review Instrument (MAStARI) method to evaluate the reli

ability of each study to determine inclusion (Joanna Briggs Institute, 2014). Hazard ratios were

used as the common measure of association in all studies Logistic regression used to model the

association of interest. Relative risk should be measured and considered odds ratios to be

relatively accurate estimates of the true relative risks. We pooled all relative risks by using a

random effects model comparing extreme categories to be equal to the inverse variance of

each study’s effect estimate. We produced forest plots to assess the multivariate adjusted

relative risks and corresponding 95% confidence intervals visually across studies. We evaluated

heterogeneity of relative risks across studies by using the Cochrane Q statistic .

3.8. Assessment of risk of bias in included studies

For each of the included studies, We measured the presence of bias

in studies creating or externally validating prognostic models using the Cochrane Risk and Bias A
ssessment (RoBANS), which is a probability of bias assessment tool designed for systematic eval

uation of diagnostic or prognostic prediction models (Page, 2018).

This contains a multitude of questions in four different fields: participants, predictors,

outcomes, and statistical analysis. Depending on the characteristics of the study, questions are

answered with yes, probably yes, probably no, no, and no information. If a domain contains at

least one signaled question as no or likely no, it is considered to be at high risk (Benton, 2016).

To be considered at low risk, all questions answered with yes or probably yes should be

included in a field. Overall bias risk is considered low risk when all domains are considered low

risk, and overall bias risk is considered high risk when at least one of the domains is considered

high risk. Two investigators assessed the possibility of bias independently (Bellou, 2019).

It describes the evaluation of development studies as well as external validation studies. Using

different populations or various statistical methods, papers also explain the creation of several

prognostic models. Therefore, discrepancies among different prognostic models produced in

the same article are anticipated in the risk of bias assessment. We have therefore chosen to

document the risk of bias evaluation per established prognostic model rather than per post.

Therefore, in the same population or in multiple different populations, articles may describe

the external validation of multiple prognostic models. For this reason, we refer to external

validation efforts and we report the risk of bias assessment per external validation effort (Naci,

Savovic, & Davis , 2017).

All the included randomized controlled studies had a low risk of bias due to their random

sequence generation, blinding of outcome assessment and intervention exposure

measurement. Some studies had unclear risk of bias, because the interventions could not be

blinded e.g., the nature of the interventions, or methodology of reporting. However, the studies

were including as the confounders/bias were considered in the reporting of results. None of the

studies included in this review reported a high risk of bias. After the full text quality appraisal

was independently undertaken by the three researchers, and following the risk of bias

assessment, studies were included in this systematic review .

2.10. Data synthesis

Outcome measures and statistical analysis, such as relative risk (RR), probability (p), Pearson

Correlation Coefficient, Confidence Interval (CI) and the statistical power of the mean were

analysed. When the data was homogenous, a Forest Plot was created to illustrate the strength

of the effect of the intervention. Due to the heterogeneity ofthe interventions and their

reported results, meta m synthesis was undertaken of the qualitative research studies.

Table .Literature Search Protocol

Structured Research Question:

What are the nursing interventions to prevent infection of a patient’s CVC

How to educate patients regarding the care of CVC

For the critically ill adult with a central venous catheter:

1. What is the frequency of line changes required to prevent central line associated bacteraemia (CLAB)?

2. What is the most effective cleaning solution/antiseptic to use when dressing the line?

3. What dressing technique (type, frequency and method of dressing) is most effective in maintaining

line integrity and minimises central line associated bacteraemia (CLAB)?

4. What flush bag solution is most effective (saline vs heparin) in maintaining lumen patency?

5. What flushing techniques (solution, frequency and methodology) are the most effective in

maintaining the patency of the unused lumens of a central line?

6. What are the competencies required by nursing staff that promote effective central line

management?

P Population (of interest)

I Intervention

C Control (group)

O Outcome (measured)

Search Strategy

Databases:

Publication years

Other search filters

English language only

Abstracts

2.11. Data analysis

Analysis of data helps to explain evidence, identify patterns, establish theories and test

hypotheses. This requires data quality, statistical data evaluation, simulation and interpretation

of results (Tartu Ulikool 2015.). In order to ensure validity, only 10 papers were used in the

study. We tried to present the information without any misrepresentation. The data are then
qualitatively and quantitatively reviewed. If it is determined that the different results of the

research can not be combined, all the results and characteristics of the individual studies in a

descriptive form; this is called a qualitative review. A meta-analysis is a statistical study in which

measures the therapeutic efficacy

The pooled estimate is the result of the meta-analysis and is generally explained with a forest

plot . The forest plot's black squares are the odds ratios (ORs) and confidence intervals of 95

percent in each sample. The square area is the weight that is reflected in the meta-analysis. The

black diamond represents the confidence interval of OR and 95 percent calculated .

It is very important to compromise biases and attempt to be objectivity when analyzing the

data.For this carefully read the abstract and the conclusion carefully. To summarize the details,

we tried our best to use simple words. Four articles on CVC nursing education, four articles on

CVC-related infection and two articles on patient education are available.

The studies examined a variety of interventions, including educational interventions, skill-mixed

interventions, interventions based on equipment, various dressings, and aseptic-based

interventions. Several studies assessed the use of different central venous line insertion

bundles, including the Institute for Healthcare Improvement (IHI).

 PRISMA 2009 Flow Diagram (Moher D, 2009)
Identification

Records identified through Additional records identified

database searching through other sources
(n = ) (n = )

Records after duplicates removed

(n = )
Screening

Records screened Records excluded

(n = ) (n = )

Full-text articles assessed Full-text articles excluded,

Eligibility

for eligibility with reasons

(n = ) (n = )

Studies included in
qualitative synthesis
(n = )
ncluded

Studies included in
Table. Summary Tables of Research Papers included

Short reference Design/Method Sample Outcomes/findings Methodological

Description Quality

Level of evidence

Level of evidence
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