You will select either a quantitative or a qualitative nursing research article (attached below). The studys main components should be summarized. A critique also co

E32 CLINICAL JOURNAL OF ONCOLOGY NURSING APRIL 2019, VOL. 23, NO. 2 CJON.ONS.ORG

B Chlorhexidine Gluconate Baths Supporting daily use to reduce central line–associated bloodstream infections affecting immunocompromised patients

Gladys N. Jusino-Leon, DNP, MSN, CMSRN, Linda Matheson, BSN, MS, PhD, and Lydia Forsythe, PhD, MA, MSN, CNOR, RN

BLOODSTREAM INFECTIONS (BSIs) ARE AMONG THE LEADING CAUSES of death in healthcare facilities (Alkilany, 2016). These infections are associated with surgeries and devices used to deliver treatments, such as central venous catheters (CVCs) and ventilators. The use of CVCs has increased, with about 300 million catheters being used in the United States; more than 5 million of those are CVCs (Kornbau, Lee, Hughes, & Firstenberg, 2015). The use of implanted ports; peripherally inserted central catheters; and tunneled, cuffed CVCs to obtain vascular access is common in oncology units. These remain in place for days to several months. The familiarity with them can make healthcare providers and patients overlook infection preventive measures; this can put patients at risk for central line–associated BSIs (CLABSIs). CLABSIs are hospital-acquired infections with a mortality rate of 12%–25% (Sandoval, 2015). A BSI is considered a CLABSI when a patient develops a laboratory-confirmed infection, with signs and symp- toms of infection more than 48 hours after the insertion of the central line (Centers for Disease Control and Prevention [CDC], 2019).

Bacteria in oncology care settings include methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). These organisms are associated with poor hand hygiene by patients, family, or healthcare providers, or inadequate care of the CVC (CDC, 2016). Infections by these two organisms are preventable and counted under the CLABSI rate for healthcare facilities (Chen, Li, Li, Wu, & Zhang, 2013). Patients with cancer also are susceptible to other organisms because of mucosal barrier injury (MBI). MBIs are the result of chemotherapy promoting the translo- cation of oral and gastrointestinal flora into the bloodstream, increasing a patient’s susceptibility to hospital-acquired infections (Metzger et al., 2015). When an intestinal organism is identified by a blood culture obtained from blood drawn from a CVC, and the patient has been neutropenic within the infection window period (three days before and three days after blood cul- ture was obtained), it is considered an MBI and nonpreventable (Agency for Healthcare Research and Quality, 2013).

The Joint Commission (2013) created a CLABSI toolkit called the CVC Maintenance Bundles that integrated evidence-based interventions and was required to be used nationwide in healthcare facilities (see Table 1). A CVC

KEYWORDS

CLABSI; mucosal barrier injury;

chlorhexidine gluconate

DIGITAL OBJECT IDENTIFIER

10.1188/19.CJON.E32-E38

BACKGROUND: Chlorhexidine gluconate (CHG)

has a broad-spectrum antimicrobial property

that has proven to be effective in prolonging skin

antisepsis and decreasing pathogens often seen in

oncology units.

OBJECTIVES: The aim was to reduce the incidence

of central line–associated bloodstream infections

in a hematology-oncology unit through the staff’s

continued adherence to the institution’s protocol

for CHG baths with wipes, and to identify barriers

and the degree to which they interfered with

optimal use of the CHG wipes.

METHODS: The project focused on supporting

staff and nurses by providing education and train-

ing on current practices to staff and patients, and

identifying barriers. Direct observation and chart

audits were the approach chosen to implement

the project.

FINDINGS: For the project study period, the unit

had three nonpreventable bloodstream infections

and zero preventable bloodstream infections.

✔

APRIL 2019, VOL. 23, NO. 2 CLINICAL JOURNAL OF ONCOLOGY NURSING E33CJON.ONS.ORG

maintenance bundle prevents infection of the catheter insertion site by promoting the implementation of aseptic techniques for ongoing catheter site care in hospitalized patients (CDC, 2019). MRSA is a type of bacteria that usually presents as a skin infection and is resistant to many antibiotics; this skin infection becomes life-threatening in the hospital setting (CDC, 2019). The use of chlorhexidine gluconate (CHG), which has a broad-spectrum antimicrobial property, has proven to be effective in decreasing and eradicating pathogens often seen in oncology units, such as MRSA and VRE (Chen et al., 2013).

A healthcare facility in the southeastern region of the United States, Emory University Hospital, was particularly concerned about the development of CLABSI events in the hematology-oncology unit. In 2011, a CVC maintenance bundle was successfully implemented on the unit, but CLABSI events continued to develop. For example, in September 2015, the CLABSI rate was about 8 events per 1,000 central line days. In December 2015, the CLABSI rate decreased to 2 events per

1,000 central line days, but by February 2016, it increased to 4 events. Whether these rates were a combination of CLABSI and MBI events is unclear. These numbers were particularly con- cerning because CLABSIs among immunosuppressed patients are life-threatening and associated with increased healthcare costs (Nelson, Angelovic, Nelson, Gleed, & Drews, 2015). In 2016, the facility added to the CVC maintenance bundle the use of CHG baths for patients with cancer on admission and daily. This entailed using CHG wipes, with the expectation that it would reduce BSIs in the unit. At the end of the fourth quarter of 2016, the unit had a CLABSI incidence rate of 5.28 per 1,000 central line days. The national goal for CLABSI events established by the Agency for Healthcare Research and Quality in 2013 was 1 event per 1,000 central line days.

Many healthcare facilities struggle to reach that goal. The staff had many theories about what was causing the develop- ment of CLABSI events in the unit. A quality improvement project was developed to identify and close the gap that

TABLE 1.

CVC MAINTENANCE BUNDLES

BUNDLE COMPONENT RATIONALE AND EXPECTATION INTERVENTION

Administration set replacement

Primary and secondary set are replaced no more frequently than 96 hours and at least every 7 days, unless contamination occurs.

ɔ When starting IV fluids, use aseptic technique; apply dated label. ɔ Change central parenteral nutrition lines every 24 hours. ɔ IV sets used intermittently should be discarded immediately after being used. ɔ Set is discarded immediately after transfusion of blood products.

Catheter access Aseptic technique used for all access to the line

ɔ Use sterile blood collection technique. ɔ “Scrub the hub” before accessing catheter.

Catheter injection ports Alcohol scrub of infusion hubs for 15 seconds before each use

ɔ Open lumens and hubs covered with alcohol-impregnated caps. ɔ Caps are changed no more than 72 hours per 7 days.

Catheter replacement Daily review of central line necessity

ɔ Review number of recent maximum-temperature episodes and recent blood cultures done and results.

ɔ Inspect catheter site. ɔ Notify team during rounds. ɔ Document ongoing need for the CVC.

Dressing Change clear dressing every 7 days. ɔ Use sterile kit. ɔ Follow institution’s dressing change protocol. ɔ Apply chlorhexidine gluconate–impregnated sponge at the insertion site.

Hand hygiene Hand hygiene at all times before manipulation of the CVC and IV system

ɔ Reminders during huddle ɔ Reminders posted throughout the unit and patients’ rooms

Healthcare personnel training All staff members are required to receive hands-on training followed by a competency evaluation.

ɔ New hired personnel receive training during residency program and orientation. ɔ Annual competency evaluation

Site inspection

Daily inspection of the insertion site for signs of possible infection: S (smell), P (pain), A (appearance), D (drainage)

ɔ Offer site care if wet, soiled, or not changed for more than 7 days. ɔ Document. ɔ Notify team.

CVC—central venous catheter Note. From “Preventing Central Line–Associated Bloodstream Infections: Useful Tools, an International Perspective,”by Joint Commission, 2013. Retrieved from https://www.jointcommission .org/topics/clabsi_toolkit.aspx. Copyright 2013 by Joint Commission. Adapted with permission.

E34 CLINICAL JOURNAL OF ONCOLOGY NURSING APRIL 2019, VOL. 23, NO. 2 CJON.ONS.ORG

CHLORHEXIDINE GLUCONATE BATHS

promoted the continued development of CLABSI events on the hematology-oncology unit. This project addressed the following question: “In immunosuppressed patients with central lines on an acute hematology-oncology unit, will increasing adherence to CHG baths bring the CLABSI rate from 5.28 per 1,000 central line days to 1 per 1,000 central line days within a 10-week period?”

Studies show that the delivery of safe, quality care at the bed- side can be hindered by a work environment that lacks key work processes (Moustaka & Constantinidis, 2010). A healthcare environment that fosters interprofessional work and commu- nication, teamwork, adequate supplies and equipment, and the reduction of unnecessary tasks promotes effective delivery of care (Lavoie-Tremblay et al., 2014). A stressful environment may result in poor decision making, lack of concentration, apathy, decreased motivation, and anxiety, impairing job per- formance and creating uncharacteristic errors (Moustaka & Constantinidis, 2010).

Methods Approval of the procedures and methods for the project was given by the healthcare facility and Capella University’s institutional review boards. The project used the engage, educate, execute, and evaluate sequence (see Figure 1). The objective of the proj- ect was shared first with the unit practice counsel, a committee designed to help improve patient care and staff satisfaction on the unit. Meeting with this group helped with understanding the staff ’s initial perceptions of the project and identifying possible barriers that could hinder its implementation. These meetings revealed the need to increase staff ’s education, orientation, and training on the institution’s protocol. Education, orientation, and training on the institution’s protocol for the use of CHG wipes were offered to staff members. The staff members were expected to explain the CHG bath with wipes during their initial assess- ment of patients on admission and every day throughout their hospitalization.

Education The first two weeks of the project included establishing a baseline about procedures and performing the procedures. This baseline period included observation and evaluation of staff providing CHG baths with wipes, review of staff members’ documentation, education, review of the institution’s protocol, and checkoffs on the institution’s protocol for CHG bath with wipes (see Figure 2). Initially, the plan was to provide patients and family members with a complete summary of possible complications that resulted from the development of CLABSI events. Leadership concern about possible legal liability changed that plan to informing patients and family members only of the possibility of extended length of stay. An educational board was designed and posted on the unit to increase patient awareness of the practice. Direct observation of the implementation of the practice was used to

FIGURE 1.

PROJECT SEQUENCE

ENGAGE

ɔ Seeking and maintaining staff engagement using motivational inter-

viewing

ɔ Initial group or one-to-one meetings with staff to review the institution’s

protocol for CHG baths with wipes

ɔ These meetings revealed staff’s need for education, orientation, and training.

EDUCATE

ɔ Education, orientation, and training on CHG baths with wipes offered to

patient care technicians; patient and family education to be focused on

how CHG baths with wipes affect length of stay

ɔ First round of direct observation of staff’s performance of CHG baths with

wipes to validate competency was conducted

ɔ Auditing of documentation found documentation to be incomplete.

ɔ Patients’ refusal of CHG baths with wipes with no indication of staff’s

intervention was identified.

ɔ Education board was created.

ɔ The need to create a group to conduct regular surveillance was determined.

ɔ Leadership expressed concern about the amount of information shared

with patients and family.

EXECUTE

ɔ CLABSI control team created

ɔ CHG champions identified

ɔ Patient education modified to share only the extension of length of stay as

the result of a CLABSI

ɔ Second round of documentation audit occurred.

ɔ Staff accountability for adherence to appropriate documentation and

patient education increased.

ɔ Staff began to identify ineligible patients.

ɔ First report from hospital’s BSI committee showed increased adherence to

institution’s protocol for CHG baths with wipes was needed.

ɔ CHG champion started to audit documentation and offered feedback to

staff.

EVALUATE

ɔ Increased awareness of staff with the practice resulted in increased

accountability.

ɔ Staff adopting the practice

ɔ Second report from the hospital’s BSI committee received 0 preventable

CLABSIs, 0 methicillin-resistant Staphylococcus aureus events, and only

three nonpreventable mucosal barrier injuries.

ɔ Interventions by the CLABSI control team and CHG champion became

more frequent. Patients’ education (on admission and throughout the

hospitalization) was more appropriate and complete. Documentation that

reflected patients’ refusal and staff’s interventions, ineligible patients, and

reasons improved.

BSI—bloodstream infection; CHG—chlorhexidine gluconate; CLABSI—central line– associated bloodstream infection

APRIL 2019, VOL. 23, NO. 2 CLINICAL JOURNAL OF ONCOLOGY NURSING E35CJON.ONS.ORG

validate staff members’ skill competency and adherence to the institution’s standard practice.

The first formal round of direct observation to evaluate how the CHG baths with wipes were being offered took place from April 10 to April 14. Audit of staff members’ documentation followed direct observation. Timely feedback was essential to promote self-awareness and a change in practice. Every month, the hospi- tal’s BSI committee shared a report on the unit’s CLABSI rate. If a patient developed a CLABSI, the chart was audited for any inter- ruption that may have occurred on standard practice throughout the hospitalization. An important part of the education offered to nursing staff members was the integration of the definition of MBI, helping them differentiate between a CLABSI and an MBI. The audits on documentation helped identify patients who continually refused the CHG baths with wipes. The phrase “CHG bath with wipes” was changed to “CHG treatment,” helping patients, family, and staff acknowledge the importance of this practice.

Execution The institution uses electronic health records to document baths, with a free-text area to include any additional information. Documentation of the CHG bath with wipes was either absent or incomplete, with the reason for refusal not explained or not fol- lowed up by the night nurse or patient care technician. Changes to

the plan included identification of strategies to address patients’ refusal (see Table 2). Once documentation improved, ineligible patients were better identified. Documentation helped identify reasons for patients’ refusal and follow-up interventions.

To facilitate adherence to the practice, a CLABSI control team was created and CHG champions were recruited. Team members offered daily reminders on the standard practice and highlighted the importance of detailed documentation. The central line dressing–change team oversaw nursing adherence to the CVC maintenance bundle. The discharge class coordinator integrated information on the CHG bath with wipes to facilitate patients’ adherence to the practice on their next admission. Surveillance of the institution’s protocol on admission and throughout the patient’s hospitalization by the CHG champions increased.

Data Analysis Increased staff accountability helped support the use of daily CHG baths with wipes. This was obtained through increasing feedback offered to the staff and using the motivational interview model when documentation was incomplete. The motivational interview included the following questions:

ɐ What are the steps to follow when offering the CHG bath? ɐ Why do you think this healthcare facility’s guidelines follow a

specific order when offering the CHG baths? ɐ How did you remember each step? ɐ If a step was missed, how sure are you about that? ɐ How will you explain the CHG baths to the patient and family?

Overall, the multiple components of the scholarly project helped identify and address barriers, adjust the implementation of the interventions as needed, and assess their effectiveness.

Results from the project were evaluated using qualitative and quantitative methods. The qualitative analysis determined staff perceptions, experiences, attitudes, and comfort with the standard practices (Bricki & Green, 2017). The quantitative anal- ysis measured the number of patients who were consistently receiving the CHG bath with wipes. This number was compared with the monthly hospital’s BSI committee report for the unit to see if the intervention was affecting and reducing the CLABSI rate. The number of patients refusing the CHG treatment and the number of times staff were adherent to documentation were used to assess the barriers identified. Descriptive statistics were used for adherence and refusal scores, and both were calculated based on the number of eligible patients on the unit every day. The unit’s CLABSI rate, reported by the hospital’s BSI com- mittee on the 15th of each month, was compared to the number of patients who received and refused the treatment.

FIGURE 2.

CHG BATHS CHECKLIST

PRACTICE DONE

Wash patient’s face with terrycloth washcloth, water, and CHG-compatible soap.

Use CHG wipes for the rest of the body:

Abdomen and back

Right leg (thigh to toes)

Left leg (thigh to toes)

Buttocks, groin, and perianal area (Do not use internally, between labia, or on tip of penis.)

Wait 30 minutes to apply lotions compatible with CHG.

Time and date CHG treatment in electronic documentation.

Assess condition of the skin daily.

CHG—chlorhexidine gluconate Note. From “Universal ICU Decolonization: An Enhanced Protocol,” by Agency for Healthcare Research and Quality, 2013. Retrieved from https://www.ahrq.gov/ professionals/systems/hospital/universal_icu_decolonization/index.html. Copyright 2013 by Agency for Healthcare Research and Quality. Adapted with permission.

IMPLICATIONS FOR PRACTICE

ɔ Integrate evidence-based practice into the nursing staff’s daily routine

to promote quality improvement of standard practices. ɔ Have a staff that is well informed, trained, and empowered to

perform their responsibilities. ɔ Use detailed documentation to identify other areas that need to be

addressed by the nursing staff.

E36 CLINICAL JOURNAL OF ONCOLOGY NURSING APRIL 2019, VOL. 23, NO. 2 CJON.ONS.ORG

CHLORHEXIDINE GLUCONATE BATHS

Results The project lasted about three months. The total number of beds in the unit is 24. Two days were chosen every week to review the number of CHG baths with wipes that were offered to eligible patients. Adherence to detailed documentation of the CHG baths with wipes by patient care technicians and nurses improved from 94% in April to a consistent 100% in June. The number of patients receiving the treatment improved at the beginning of the second month, but some patients still refused it. During the first month, the hospital’s BSI committee reported two preventable CLABSIs, one nonpreventable MBI, and zero MRSA events, with a CLABSI rate of 6.07 per 1,000 central line days. The two preventable CLABSIs were tracked back to a patient who refused to receive the CHG baths with wipes 16 days of his 32 days in the hospi- tal, reflecting 50% refusal throughout his hospitalization stay. The other CLABSI was tracked back to a patient who refused the CHG baths with wipes 7 days toward the end of her 34 days in the hospital, reflecting 20% refusal throughout her hospitaliza- tion stay. This patient showed signs of infection in the central line insertion site, but the hematology-oncology service did not remove the central line until the completion of the treatment while administering IV antibiotics. Whether this was requested by the patient is unknown.

Following the implementation of the project, the report obtained from the BSI hospital committee for the second and third month showed the development of zero CLABSI events on

the unit, zero MRSA events, and only three MBI events. The final CLABSI rate for the unit reported by the BSI hospital committee was 5.86 per 1,000 central line days, which reflects the three non- preventable MBIs developed in the third month.

Discussion Patients’ refusal to receive the CHG baths with wipes was identified as a barrier to complete adherence of the unit to the institution’s protocol. Occasional patient refusal and inconsis- tencies in documentation were two major barriers to complete unit adherence to the protocol for CHG baths with wipes.

TABLE 2.

BARRIERS TO CHG BATHS

BARRIER REASON INTERVENTION RECOMMENDATION

Patients’ refusal CHG leaves a sticky film on the body, making patients uncomfortable.

ɔ Increased education ɔ Patients were given the choice

to do the CHG bath with wipes at night.

ɔ Night staff to follow up

Staff to continue education using lab- oratory results as a tool to explain to patients the need for the intervention

Ineligible patients Allergic to CHG or skin not intact ɔ Patients were not counted under

the number of patients to receive the CHG bath with wipes.

–

Leadership requested that education be limited only to the impact of CLABSI on patients’ length of stay.

Concerned about legal liability related to the amount of information shared with patients and family regarding the effect of CLABSI on the hospitalization

ɔ Education was limited to the impact of CLABSI on patients’ length of stay.

ɔ Patients’ laboratory results were used twice by the project leader to explain the need for the interven- tion. As a result of this intervention, patients agreed to receive the CHG bath with wipes.

The use of laboratory results as a tool to explain to patients the need for the intervention should be considered in a future project.

The project time frame was limited to only 10 weeks.

Doctor of Nursing Practice project ɔ CLABSI control team created, CHG

champion established for continu- ation of the practice

Identify more CHG champions, promote the intervention, educate patients more frequently, and extend the project to 6 months to a year.

CHG—chlorhexidine gluconate; CLABSI—central line–associated bloodstream infection

“Increased staff accountability helped support the use of daily chlorhexidine gluconate baths with wipes.”

APRIL 2019, VOL. 23, NO. 2 CLINICAL JOURNAL OF ONCOLOGY NURSING E37CJON.ONS.ORG

Project results identified a gap in the staff members’ and patients’ understanding of the rationale behind the institu- tion’s protocol and the purpose of the CHG baths with wipes. Educating the staff on proper documentation helped identify barriers. Differentiating between CLABSI and MBI helped staff members understand the importance of their interventions. In private conversation with patient care technicians after project completion, they expressed feeling more confident when edu- cating patients about CHG baths with wipes on admission and throughout their hospitalization. Patients and family members also indicated better understanding of the protocol and were better informed and more willing to receive the CHG baths with wipes.

The findings in this project are congruent with or supportive of previous studies conducted to verify how effective the use of CHG baths with wipes was in reducing CLABSI events in other hospital areas besides the intensive care unit (Whited & Lowe, 2013). A study conducted by Hines et al. (2015) showed patient refusal and lack of staff time as major barriers to daily CHG bathing. Offering the CHG baths with wipes at night helped increase patients’ adherence to the practice.

Although an improvement in the quality metric for CLABSI rates in this unit was evident, more than 10 weeks should be allowed to explore options that also could help reduce MBI incidence.

Limitations The CHG wipes left a sticky film on the patients, making them uncomfortable and more inclined to refuse the CHG baths with wipes. Concern of the director of the hematology-oncology unit about a complete disclosure of possible CLABSI compli- cations limited the information offered to patients and their family members. The information the first author prepared to educate patients and their family members had to be changed, and new venues had to be found. Offering information regard- ing the patients’ immune system and how neutropenia increases their risk of developing a preventable CLABSI or nonpreventable MBI was a good option. The project had to be implemented in 10 weeks, making time constriction the second limiting factor; how- ever, in that short time, an improvement in the adherence to the institution’s protocol was evident.

Conclusion A decrease in CLABSI events is considered an indicator of quality nursing care (Montalvo, 2007). Evidence-based prac- tices and preventive initiatives will be effective in reducing the incidence of CLABSIs if healthcare providers adhere to guide- lines and protocols established by their healthcare institution. Patient education is crucial to obtaining informed consent and having patients and their family members engaged in the institution’s protocol. The use of laboratory results to educate

immunocompromised patients is an effective tool to help them understand the importance of adhering to the institution’s protocol. This project could be extended to other areas in the hospital. Leadership, in this sense, opens the door to countless opportunities to be more effective in health promotion and dis- ease prevention.

Gladys N. Jusino-Leon, DNP, MSN, CMSRN, is a nurse clinician at the Gwinnett

Medical Center in Lawrenceville, GA; Linda Matheson, BSN, MS, PhD, is a faculty

member in the School of Nursing and Health Sciences at Capella University in

Minneapolis, MN; and Lydia Forsythe, PhD, MA, MSN, CNOR, RN, is the chief

executive officer of Londes Strategic Healthcare Consulting in Oklahoma City, OK.

Jusino-Leon can be reached at [email protected], with

copy to [email protected] (Submitted August 2018. Accepted November 27,

2018.)

The authors gratefully acknowledge Katherine Renee Spinks, MSN, APRN,

ACNS-BC, AOCNS®, and Patricia Crabtree, BSN, MHA, RN, NE-BC, for their leader-

ship and guidance throughout the implementation of the project.

The authors take full responsibility for this content and did not receive honoraria

or disclose any relevant financial relationships. The article has been reviewed by

independent peer reviewers to ensure that it is objective and free from bias.

REFERENCES

Agency for Healthcare Research and Quality. (2013). Eliminating CLABSI: A national patient

safety imperative: Final report. Retrieved from https://www.ahrq.gov/professionals/quality

-patient-safety/cusp/clabsi-final/clabsifinalsum.html

Alkilany, M. (2016). CLABSI during neutropenia among oncology adults post chemotherapy.

Middle East Journal of Nursing, 10(3), 25–27.

Bricki, N., & Green, J. (2017). A guide to using qualitative research methodology. Retrieved

from http://fieldresearch.msf.org/msf/bitstream/10144/84230/1/Qualitative%20

research%20methodology.pdf

Centers for Disease Control and Prevention. (2016). National and state healthcare-associated

infections progress report. Retrieved from https://www.cdc.gov/HAI/pdfs/progress-report/

hai-progress-report.pdf

Centers for Disease Control and Prevention. (2019). Blood-stream infection event (central

line–associated blood-stream infection and non-central line associated blood-stream

infection). Retrieved from https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabs

current.pdf

Chen, W., Li, S., Li, L., Wu, X., & Zhang, W. (2013). Effects of daily bathing with chlorhexidine and

acquired infection of methicillin-resistant Staphylococcus aureus and vancomycin-

resistant Enterococcus: A meta-analysis. Journal of Thoracic Disease, 5, 518–524. https://

doi.org/10.3978/j.issn.2072-1439.2013.08.30

Hines, A.G., Nuss, S., Rupp, M.E., Lyden, E., Tyner, K., & Hewlett, A. (2015). Chlorhexidine bathing

of hospitalized patients: Beliefs and practices of nurses and patient care technicians,

and potential barriers to compliance. Infection Control and Hospital Epidemiology, 36,

993–994. https://doi.org/10.1017/ice.2015.92

Joint Commission. (2013). Preventing central line–associated bloodstream infections: Useful

tools, an international perspective. Retrieved from https://www.jointcommission.org/

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E38 CLINICAL JOURNAL OF ONCOLOGY NURSING APRIL 2019, VOL. 23, NO. 2 CJON.ONS.OR

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