Nursing Care for Patients with Central Venous Catheter: A Systematic Review and Meta-Analysis

Abstract

Introduction: The central venous catheter use can put risk to patients’ safety in the intensive care unit. Nursing care requires continuous assessment to ensure adverse events reduction.
Objective: To demonstrate the evidence that nursing care in the intensive care unit reduces adverse events related to patients’ safety during insertion, maintenance, and removal of a central venous catheter.
Material and Methods: Systematic review and meta-analysis. Eight databases were searched using key terms. Two researchers independently assessed data. The Kappa coefficient was calculated. The risk of bias and the quality of the evidence were analyzed.
Results: Eight studies were included. The Kappa coefficient was 0.64 and 0.73. Although the quality of the evidence was very low, nursing care for patients’ safety in the maintenance of central venous catheters were identified. There was no significant effect of the nursing care bundles related to central venous catheter maintenance on central line-associated bloodstream infection. The methodological quality of the included studies was moderate to severe in observational studies and a high risk of bias for the randomized design.
Conclusion: Nursing care, when appropriate and clinically evaluated, contributes to critical patients' safety reducing adverse events at all the moments during the use of central venous catheters.

Full text

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J Nurs Health Sci | Volume 10 | Issue 5 | December, 2020
Research & Reviews: Journal of Nursing & Health Sciences
Nursing Care for Patients with Central Venous Catheter: A
Systematic Review and Meta-Analysis
Stefhanie Conceição de Jesus1, Kátia Cilene Godinho Bertoncello2, Graziele Telles Vieira1, Aline Diane
1, Dulcinéia Ghizoni Schneider2, Inácio Alberto Pereira Costa3
Anna Carolina
Raduenz Huf Souza1, Eneida Patrícia Teixeira1, Adalia Edna Fernando Chipindo1, Zannis
De Andrade1, Débora Batista Rodrigues1, Cheila Maria Lins Bentes ,
4
1Graduate Nursing Program, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
2Department of Nursing, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
3Federal Institute of Santa Catarina, Florianopolis, Santa Catarina, Brazil
4University of Amazonas State, Amazonas, Brazil
5Graduate Nursing Program, Federal University of Santa Catarina, and REPENSUL Institute,
Florianopolis, Santa Catarina, Brazil
Research Article
INTRODUCTION
Nursing care can determine different outcomes for patients in intensive care units (ICUs). The technological prole of these
units allied to the clinical patient’s condition contributes to a dynamic and complex system, conducive to the occurrence of
unfavorable outcomes [1]. Non-tunneled devices, like central venous catheters (CVCs), is a technology widely used in critical
patients’ treatment; however, the CVC use is also associated with adverse events [2].
Adverse events are episodes of incidents that result in damage to the patients [3]. Bloodstream infections (BSI) are the main
problems related to CVC, but extravasation/inltration, hematoma/ecchymosis, catheter embolism, gas embolism, deep venous
thrombosis, catheter obstruction, and catheter rupture can also occur [4]. Therefore, the CVC use is a risk to patients’ safety in ICU,
because of that, continuous assessment of the care provided is necessary.
In the consulted literature, nursing care is directed towards the prevention and control of BSI, especially central line–
associated bloodstream infection (CLABSI) [5,6].
ABSTRACT
Introduction: The central venous catheter use can put risk to
patients’ safety in the intensive care unit. Nursing care requires
continuous assessment to ensure adverse events reduction.
Objective: To demonstrate the evidence that nursing care in the
intensive care unit reduces adverse events related to patients’ safety
during insertion, maintenance, and removal of a central venous catheter.
Material and Methods: Systematic review and meta-analysis.
Eight databases were searched using key terms. Two researchers
independently assessed data. The Kappa coefcient was calculated.
The risk of bias and the quality of the evidence were analyzed.
Results: Eight studies were included. The Kappa coefcient was
0.64 and 0.73. Although the quality of the evidence was very low,
nursing care for patients’ safety in the maintenance of central venous
catheters were identied. There was no signicant effect of the nursing
care bundles related to central venous catheter maintenance on central
line-associated bloodstream infection. The methodological quality of the
included studies was moderate to severe in observational studies and a
high risk of bias for the randomized design.
Conclusion: Nursing care, when appropriate and clinically evaluated,
contributes to critical patients' safety reducing adverse events at all the
moments during the use of central venous catheters.
Received date: 01/12/2020
Accepted date: 17/12/2020
Published date: 24/12/2020
*For Correspondence
Maria de Lourdes de Souza, Rua Delno Conti,
s/n-Trindade, Florianopolis, Santa Catarina,
CEP88040-370, Brasil.
E-mail: repensul@uol.com.br
Tel: +55(48)991618333
Keywords: Review, Nursing care, Nurse,
Catheters, Intensive Care Units.
, Juliana Fernandes da Nobrega ,
N3
Benevides
Maria de Lourdes de Souza5*
Colaço

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The health care for BSI prevention and control are compiled in conjunction with care activities directed to the patient care
team, as in the case of care bundles. They are a set of interventions developed based on guidelines and applied in the clinic for
a dened population of patients and environments [7]. The care bundles were initially introduced by the Institute for Healthcare
Improvement (IHI) in 2001 with a focus on improving care in the ICUs [7]. They aimed at the improvement of critical care processes
towards high levels of reliability, with a consequent improvement in patient outcomes [7].
In 2011, was published guidelines recommended care bundles aiming at reducing intravascular catheter-related infections.
These recommendations drove changes in the clinical practices of the entire patient care team, especially for healthcare personnel
who insert intravascular catheters and for persons responsible for surveillance and infection control [8].
The management of adverse events is important in health services since a patient with damage resulting from an adverse
event has a higher economic cost, a longer hospital stay, a higher probability of readmission in 30 days, and a higher probability
of death [9].
Studies have shown that nursing care contributes to better patient health outcomes, therefore being a care quality predictor
[10,11]. Thus, it is important not only to identify the care that is provided by nurses for patients with CVC but also to demonstrate the
evidence about these nursing care for patient safety in ICU, being, therefore, the aim of this systematic review.
LITERATURE REVIEW
This review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P)
for structuring the protocol [12]. The protocol was previously registered on the International Prospective Register of Systematic
Reviews platform (PROSPERO - number CRD42020152630) [13].
The acronym PICO was used to construct the guiding question for this review. In this, the letter P represents the population/
participant; the letter I represents the intervention/procedure; the letter C represents the comparison (optional in the studies);
and the letter O represents the outcomes [14]. This review was guided by the following question: “What is the evidence that the
nursing care in the intensive care unit reduces adverse events related to patient safety with respect to the insertion, maintenance
and removal of central venous catheters?”
Databases were systematically searched on the 12th of November, 2019. Databases included MEDLINE accessed by the
National Library of Medicine (PubMed) and by the Virtual Health Library (VHL); Latin American Health Sciences Literature (LILACS);
Nursing Database (Base de dados em Enfermagem, in Portuguese - BDENF); Cumulative Index to Nursing and Allied Health
Literature (CINAHL); Scopus; Web of Science (WOS); Cochrane Library; and Scientic Electronic Library Online (SciELO). Details of
the PubMed search strategy are presented in Table 1.
Table 1. Search strategy applied in the PubMed database.
Database Search strategy
PubMed
("Nursing Care" OR nurses AND catheters OR "Catheterization, Central Venous" OR "Central Venous Catheters" OR "Central
Venous Catheter" OR "Vascular Access Devices" OR "Vascular Access Device" OR "Vascular Access Ports" OR "Vascular Access
Port" OR catheterization OR catheterizations OR cannulation OR cannulations AND "Intensive Care Units" OR "Intensive Care
Unit" AND adult OR "Young Adult" AND ("2010/01/01" [PDAT] : "2019/11/11" [PDAT]) AND (English [lang] OR Portuguese [lang]
OR Spanish [lang]))
The following inclusion criteria were adopted: Randomized Clinical Trial (RCT) study; quasi-experimental study; analytical
observational studies; in English, Portuguese or Spanish; published from 2010 to 2019 (date prior to collection); studies with
reduction of adverse events or patient safety as outcome; studies that present nursing care to adult patients with CVCs in ICUs,
or with indication of installation and/or removal of the catheter.
The exclusion criteria were: theses, dissertations, editorials, review studies; studies not fund in full length; studies with
pediatric or neonatal populations; studies with patients using: arterial catheters, or catheters for hemodialysis, or catheters for
plasmapheresis; studies with patients using catheters inserted in peripheral veins; and use of a tunneled catheter.
The reference focus dened for the search period from 2010 to 2019 was given by the publication of the guidelines in 2011
on the adoption of care bundles [8].
References were exported to the EndNote Basic™ (Clarivate Analytics). Those indexed in more than one database were
excluded. Two researchers independently examined the titles and/or abstracts. For this step, an electronic tool was used to
enable independent reading and evaluation by researchers - Rayyan® [15].
The selections agreement level was analyzed using Kappa coefcient with a 95% Condence Interval (CI). The Kappa
coefcient allows to exclude the hypothesis of concordant selections due to chance [16]. The following classications were adopted
for the numerical indices identied: < 0.00, poor agreement; 0.00 - 0.20, slight agreement; 0.21 - 0.40, reasonable agreement;
0.41 - 0.60, moderate agreement; 0.61 - 0.80, substantial agreement; and 0.81 - 1.00, almost perfect agreement [17].
Full-texts of potential articles were reassessed after the rst screening. The pair of researchers independently read full-texts

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of these articles to rene the nal selection. The results obtained in this stage were also submitted to the agreement level analysis
using Kappa coefcient, with 95% CI. Disagreements were resolved based on the evaluation by a third researcher.
Data were extracted in a spreadsheet built in Microsoft Excel®, version 2019, with the following headings: rst author; year
of publication; country; title of the study; study aim; study design; description of the nursing care; moment of the nursing care;
and outcomes of the nursing care.
The synthesis of evidence was generated from the results of all selected studies. The Grading of Recommendations
Assessment, Development and Evaluation (GRADE) was applied [18]. The grading of the quality of the evidence determined by the
evaluators can reach one of four different levels by applying the GRADE, namely: high, moderate, low and very low [18]. The online
tool GRADEpro GDT was used for this evaluation and summarization [18].
Applying the GRADE, ve criteria allow reducing the evidence level: risk of bias, inconsistency, indirect evidence, imprecision,
and publication bias. By the other hand, three criteria allow increase the degree of condence in the effect estimate, and thus,
raise the level of quality of the evidence in studies that were not previously downgraded by the above criteria. These criteria are
great magnitude of effect, dose-response gradient, and factors of residual confusion [18].
We used the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool for the observational studies [19]. The
ROBINS-I tool makes it possible to evaluate seven domains: bias due to confounding; bias in selection of participants into the
study; bias in classication of interventions; bias due to deviations from intended interventions; bias due to missing data; bias
in measurement of outcomes; and bias in selection of the reported result. In this case, risks of bias that can occur from the pre-
intervention, intervention and post-intervention stage of the study are evaluated [19].
The option to use ROBINS-I is available in the GRADEpro GDT; its application inuences the nal estimate of the evidence,
giving greater weight to observational studies, with the following possibilities for grading the risk of bias: low, moderate, serious,
critical, and no information [18].
We used The Cochrane Collaboration - Risk of Bias (RoB 2) tool to assess the risk of bias in RCTs. This tool allows the
evaluation of the randomization process, deviation from the intended interventions, the missing outcome data, measurement of
the outcomes, and selection of the reported results. In this tool, the possibilities for classifying the risk of bias are as low, high or
uncertain risk of bias [20].
For studies considered comparable and relatively homogeneous in terms of design, interventions, and outcomes, a meta-
analysis was performed using Review Manager 5.4®, summarizing the results using the Mantel-Haenszel model, Chi-Square test
and interclass correlation statistics (I²) [21]. Signicant heterogeneity was dened as I² > 50% or p < 0.05 with the Mantel-Haenszel
Chi-Square test. The results were presented with 95% condence intervals (95% CI). Statistical signicance was considered p <
0.05.
The report of this review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
guidelines [22]. In addition, tables and boxes were adopted to present the results as to the characteristics of the studies, as well
as the evaluations obtained from the GRADEpro GDT. The classications from the application of the tools for assessing the risk of
bias in the studies were presented in the form of graphs from an electronic tool - robvis [23].
RESULTS
Databases searches identied 613 records. Were excluded 224 of these due to duplication and 331 were excluded in the
rst screening. A Kappa coefcient was 0.64 of the agreement. Fifty-eight articles were read in full length, of which nine were
included and 49 were excluded, as shown in detail in Figure 1. Kappa coefcient of 0.73 agreements.

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Figure 1. Flowchart of the route to identify the studies and selection for inclusion. Note: LILACS: Latin American Health Sciences Literature;
BDENF: Nursing Database (Base de Dados em Enfermagem, in Portuguese); CINAHL: Cumulative Index to Nursing and Allied Health Literature;
Cochrane: Cochrane Library; SciELO: Scientic Electronic Library Online (SciELO).
A study, with RCT design, provided results for the publication of two articles in different journals. Therefore, although nine
articles are counted, they correspond to eight studies, which were used for the synthesis of evidence.
The characteristics of the eight studies are summarized in Table 2. The eight studies were developed in four different countries,
of which one was in Brazil (1/12.5%). The majority was developed in the United States of America (4/50.0%), followed by Turkey
(2/25.0%), and India (1/12.5%). With the exception of one RCT (12.5%), all other studies were observational, of before and after
type (7/87.5%). The works were published from 2012 to 2018, the majority in 2012 and 2014, with two publications (25.0%) in
each year. In 2018, 2017, 2016 and 2015, there was one (12.5%) publication each year.
Table 2. Summary of the included studies (n = 8).
Author/ Year/
Country Study aim and design Design Nursing care Care Moment Outcomes
Fox et al., 2015/
USA [24]
To investigate a new
protocol of patients’
HH to reduce infection
rates and improve the
compliance with HH
among ICU nurses.
Observational
To apply the patient’s
HH protocol with 2%
chlorhexidine towels, 3
times/day
CVC maintenance *1.1 to 0.50 CLABSI (p =
0.64) 9 months without
infection
To perform HH before
and after contact with
the patient
CVC maintenance
Kahn et al., 2014/
USA [25]
To determine whether
remote screening by
nurses and the request
for EBP, using an elec-
tronic health record,
could affect the provi-
sion and results of care
in the ICU.
Observational
To perform remote
monitoring, from the
EHR, of the need to
assess the continuity
of use of the CVC
CVC maintenance
*0.72 to 0.77 CLABSI. Infec-
tion number from 16 to 32
(p = 0.84)
Kaya et al., 2016/
Turkey [26]
To determine the effect
of a Nursing Care Pro-
tocol on the prevention
of CLABSI in a neurosur-
gery ICU.
Observational To apply a nursing care
protocol CVC maintenance
CLABSI number from 9
(11.3%) to 4 (5.0%) (p =
0.14)

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Munoz-Price et al.,
2012/USA [27]
To determine the effec-
tiveness of a series of
interventions for reduc-
ing CLABSI rates.
Observational
Phase 2: Friction of
intravenous ports
for 15 seconds with
single-use chlorhexi-
dine swabs
CVC maintenance Each ICU (A, B and C) ad-
hered to a number of differ-
ent interventions; ICU A: Sta-
tistically signicant CLABSI
reduction in all phases; ICU
B: No signicant CLABSI
reduction between phase 1
(pre-intervention) to phase
2; ICU 3: Signicant CLABSI
reduction from phase 1
(pre-intervention) to phase
3.
Phase 3: Daily baths
of patients with 2%
chlorhexidine wipes
CVC maintenance
Phase 4: Daily rounds
of the Nursing Man-
ager and the Bedside
Nurse on each patient
to ensure compliance
with a checklist of
goals
CVC maintenance
Pedrolo et al.,
2014/ Brazil [28,29]
To evaluate the effec-
tiveness of the chlorhex-
idine antimicrobial
dressing, comparing it
with gauze and tape; to
identify factors related
to the occurrence of
infection, local reaction
and poor xation of CVC
dressings.
RCT
Transparent adhesive
dressing integrated
into a gel pad contain-
ing 2% chlorhexidine
gluconate; Daily
assessment; Change
every seven days or as
needed.
CVC maintenance
CLABSI number from 5
(11.9%) to 6 (13.9%) (p
= 0.51). There was good
xation and high incidence
local reaction to dressings
(variables without statisti-
cally signicant difference).
Signicant association of
CVC permanence time > 5
days and infusion of blood
components and PBI
Gauze dressing and
microporous tape;
Daily assessment;
Change every 48 hours
or as needed.
CVC maintenance
Pfaf et al., 2012/
USA [30]
To compare the efcacy
of a new one-piece oc-
clusive dressing with
chlorhexidine gluco-
nate, with a dressing
plus a chlorhexidine
gluconate patch, in
maintaining low rates of
CLABSI in the ICU.
Observational
To change one-piece
occlusive dressing with
chlorhexidine gluco-
nate
CVC maintenance
* 0.53 to 0.52 CLABSI rate
To change two-piece
dressing with chlorhex-
idine gluconate
CVC maintenance
To apply a care bundle CVC maintenance
Sahni et al.,
2017/ India [31]
To establish the
incidence of VAP and
CLABSI, intervening in
the education, training
and feedback of nurses
and analyzing its impact
on the incidence of VAP
and CLABSI.
Observational
To perform HH CVC maintenance
*7.90 to 1.73 CLABSI rate
(p < 0.05)
To apply a care bundle CVC maintenance
Yazici et al.,
2018/Turkey [32]
To evaluate the ef-
fectiveness of a care
bundle with the objec-
tive of preventing the
three most frequent
infections in the ICU.
Observational To apply a care bundle CVC maintenance
* 8.90 to 9.90 CLABSI rate
(p = 0.24). CLABSI number
from 10 to 10.
* Rate calculated per 1,000 days of CVC use. USA: United States of America; HH: hand hygiene; CVC: central venous catheter; CLABSI: central
line–associated bloodstream infection; ICU: intensive care unit; EBP: evidence-based practices; EHR: electronic health record; VAP: ventilator-
associated pneumonia; RCT: randomized clinical trial.
All studies CLABSI as the primary outcome. However, other outcomes were evaluated, such as the ability of the dressing to
develop a local reaction (characterized by maceration, hyperemia, aking or itching in the region of contact between the dressing
and the skin) and xation of the dressing to the skin. In general, the nursing cares goals were to reduce the CLABSI, although some
aimed at zero rates. The units of measurement of infection were presented both in percentages and also by calculating the rate
per 1,000 days of catheter use. All nursing cares were directed to CVC maintenance.
Among the identied nursing cares, care bundles were more frequent. In three studies, bundles were implemented by
nurses to patients using CVC [30-32]. However, only one study described the nursing cares, namely: daily assessment of the need
for continuity of the CVC use; daily assessment of the need for CVC dressing; evaluation of the dressing as to proper application;
identication with the date on the dressing; evaluation of the need to replace uid sets [32].

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We conducted a meta-analysis to assess the nursing care bundle. We compared with before the intervention. Two studies
provided the data [26,32]. The other studies were not included due to heterogeneity, in addition to the absence of data that could
be compared. The results pointed in favour of the intervention. In other words, there was a reduction due to the implementation
of nursing care bundles. However, this nding was not statistically different between the groups (RR 0.74; 95% CI 0.38-1.43; p =
0.37) as presented in Figure 2.
Figure 2. Forest plot showing results of two studies that evaluated the application of nursing care bundles to patients using central venous
catheter in the intensive care unit.
Care protocols were also identied in the studies analyzed. They included: the Hand Hygiene Protocol of patients with 2%
chlorhexidine towels, three times a day [24]; and Care protocol for the CLABSI prevention in a neurosurgical ICU built-in line with the
suggestions of the CDC [26].
Two different monitoring possibilities were obtained from the studies: remote monitoring and on-site monitoring. It is also
noteworthy that remote monitoring was performed by nurses with experience in the ICU (minimum three years), by screening from
the electronic medical records [25], while on-site monitoring was conducted by a pair of professionals, the Nursing Manager and
the Bedside Nurse [27].
In addition to the on-site monitoring by nurses (manager and clinician), in the same study, other care measures for maintaining
the catheter were identied. The following precautions were taken: friction of intravenous ports for 15 seconds with single-use
chlorhexidine swabs; and daily baths with 2% chlorhexidine wipes [27].
Different dressing coverages at the insertion site of the CVC were compared, highlighting chlorhexidine gluconate-
impregnated dressing. All dressing evaluated were effective for the related outcomes. The two types of dressing impregnated with
chlorhexidine gluconate (a 1-piece group and another 2-piece group) maintained low rates of BSI, although the 1-piece coverage
was economically more viable [30]. In addition, both the dressing integrated with a gel pad containing 2% chlorhexidine gluconate
and the gauze dressing and microporous tape contributed to the CLABSI reduction, local reaction, and resulted in good dressing
xation [28,29].
In the analyzed literature, other factors were signicant association with the occurrence of local reactions: the catheter’s
length of stay greater than ve days; the number of dressing changes; and the insertion site. In addition, there was a signicant
relationship between poor xation and more than two changes with chlorhexidine dressing, and between catheters inserted in the
jugular vein and dressing in gauze [28].
Nursing care regarding the management of the use of catheters was identied. There was a signicant association with the
administration of blood components and the occurrence of BSI, with a 10.29-fold higher risk in the group that used a chlorhexidine
antimicrobial dressing; in addition, catheter’s stay of more than ve days had an eight-fold higher risk of developing an infection
in the group that used gauze dressings and microporous tape [28].
Only three studies provided data regarding nurses’ adherence to care measures. As for hand hygiene before getting in
contact with the patients, there was an increase in adherence of 66% after the intervention, compared to 35% before the
intervention; after contact with the patients, the increased from 66% to 79% [24]. As for the friction of the intravenous entry ports
with chlorhexidine swabs, there was 100% adherence; however, the median time of friction was nine seconds [27]. Worsening of
adherence related to care with dressing with CVC insertion was identied. The dates of exchanges were not recorded in 51.7%
of the observations during the implementation of the care bundles. Furthermore, the nurses’ adherence was monitored for

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three months after implantation of the care bundles, a decreased to 30.8%, in the period of implantation of the care bundles,
adherence was 47.7% [32].
The risk of bias was assessed for each study and is presented in Figure 3. In general, weaknesses in reports were identied
among the studies. The RCT was classied as having a low risk of bias in the rst three domains evaluated, related to randomization,
deviation from the intended interventions, and missing data; and high risk of bias was detected for the domains of measuring
the outcome and selective reporting of results, resulting in a high risk of bias. As for the observational studies, three presented
serious limitations related to bias due to confounding, and this was decisive for the nal estimate, despite better results in the
other domains. Four studies had a general classication as a moderate risk of bias. Limitations were identied in bias due to
confounding in three studies, bias in the selection of participants in one study; the bias in the measurement of outcomes in two
studies; and bias in the selection of the reported result in one study.
Figure 3. Domains and classication of risk of bias. The ve domains and the general classication of the clinical trial assessed using RoB 2 are
presented in A; the seven domains evaluated using ROBINS-I and the general classication of observational studies are presented in B.
Although the studies answer the same question given from the PICO strategy, they were divided into two groups due to
the different methods and designs for evaluation by the GRADE as presented in Table 3. Substantial limitations in observational
studies were due to inconsistency - heterogeneous studies; and indirect evidence because different interventions were observed.
In the RCT evaluation, limitations were identied in the risk of bias according to RoB 2; and inaccuracy due to the small sample size.
Table 3. Evaluation of the GRADE criteria and level of evidence, using the GRADE pro GDT tool.
Number of Studies Risk of bias Inconsistency Indirect evidence Inaccuracy Others* Level of evidence
7 Serious Very serious Very serious Serious None ⨁◯◯◯
Very low
1 Very serious Not serious Not serious Very serious None ⨁◯◯◯
Very low
*Publication bias, large-magnitude effect, dose-response gradient, residual confounding factors.
DISCUSSION
To our knowledge, this is the rst systematic review to demonstrate the evidence that the nursing care in the ICU reduces
the occurrence of adverse events related to the safety of patients using CVC, related to its insertion, maintenance, and removal.
In this study, it was found that nursing care contributes to the safety of patients using CVC in ICUs, but the evidence is supported
in very low quality.
The assessment of the risk of bias with the use of validated tools revealed weaknesses in the methods adopted in the
studies. Most studies applied a before and after design, which is prone to bias, while only one RCT was included in the analyses.
Randomized clinical trials are more rigorous in terms of design when compared to other study types[19]. Therefore, these results
limit the possibility of generalizing the ndings due to the internal factors of the included studies.

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Given the possibility of comparing the studies, a meta-analysis was carried out to investigate the effect of the application of
nursing care bundles in the maintenance of catheters, in which, there was a trend towards a non-signicant reduction in CLABSI.
Considering they are sets of care that can be applied in their entirety or not, depending on the demand for care, conducting a
subgroup analysis for each component is important. Comparisons between the adherences of nurses to each item of care bundles
are required.
Studies are developed to assess the impact of implementing care bundles within the multidisciplinary team. The following
practices are present in their composition: hand hygiene before insertion of the catheter; use of a sterile barrier with maximum
precautions, such as a cap, mask, apron, gloves, and sterile eld to cover the entire body of the patient; and use of chlorhexidine
for skin preparations (with spontaneous drying before insertion of the catheter); avoiding the femoral vein, if possible, and
removing catheters when they are no longer needed; and the inclusion of kits composed of materials necessary for the insertion
of central catheters [8].
In the case of nursing care, these care bundles encompass techniques of the profession. In this study, the following items
were identied in the care bundles: daily assessment of the need for continuity of use of the CVC; daily assessment of the need for
a CVC dressing; evaluation of the dressing as to proper application; identication with the date on the dressing; evaluation of the
need to replace uid sets [32]. Other activities are also listed in the literature, related to these bundles: education and training in
relation to CVC management; performing hand hygiene; use of sterile gloves (or no-touch technique); dressing with 0.5% alcoholic
chlorhexidine or isopropyl alcohol, and spontaneous drying; use of the pulsatile discharge technique when the blood returns to
CVC; and CVC lumen exclusive for the administration of parenteral nutrition [33].
All the nursing care identied in the studies were directed to maintaining the catheter. This nding is in line with the statement
that most complications related to the catheter occur during the period of maintenance of the device [34].
Daily assessment of the need for continuity of use of the CVC is part of the best practices for the maintenance of the
catheter. In the results observed in this study, it was identied that monitoring - remote or bedside - did not constitute an isolated
intervention; resources such as the clinical experience of the nurse or discussion by a pair of professionals were associated.
Monitoring, also called daily rounds, are surveillance to monitor the achievement of stipulated goals [35]. When performed remotely
is called telemedicine in the ICU (Tele-ICU) [36]. It is a practice used not only by nurses but also by other team professionals [36]. It is
shown that interventions to reduce the unnecessary use of CVCs contribute signicantly to reducing the BSI rates in adults [35,36].
As for adverse events, CLABSI was the primary outcome assessed in all studies. Although several adverse events are reported
in the context of patients using CVC, the impact of Healthcare-Associated Infections (HAIs) has resulted in different health services
and directed the focus of publications on this theme [4]. The scenario of this event related to CVC is also observed in Brazil and
has caused changes in the clinical practice of nurses. Among the main changes identied in the consulted literature, there is the
implementation of evidence-based quality improvement projects [33].
The improve care practices for patients using CVC in the ICU are especially for the prevention of infection. In general, as
identied in the articles included in this review, the goals of the care institutions are directed at achieving zero infection rates,
based on a gradual reduction of events [37]. The maintenance of these rates at zero level does not yet occur in many health
institutions, mainly in ICUs, there is a need to manage other factors such as the behaviors of adherence of professionals inserted
in ICUs.
In the analyzed literature, we observed an assessment of rates of adherence of nurses, which, in general, were high,
contributing to the surveillance of these infections. Studies have low rates of CLABSI when the adherence of professionals to
the guidelines is greater than or equal to 95% [5]. Therefore, it requires that the number of patients is planned known [38]. In
Brazil, adherence rates are considered high [39]. It is also registered in the literature that, there is an inconsistency between the
knowledge of the nursing team and adherence to practices; there is a need to implement continuing education for the control and
prevention of these infections [40,41].
Only knowing the recommendations for clinical practice does not imply adherence by professionals. As observed in the
literature included in this review, there was high adherence to the friction of catheter connectors; in turn, the recommended
maximum friction time was not practiced [27]. This results in compromised adherence when time estimates are needed for activities.
Other factors directly inuence patient safety and should be considered when dealing with CLABSI. Studies indicate that
the lack of nurses and the lack of an appropriate organizational culture signicantly interfere in better results as to the incidence
of CLABSI [42]. It is not enough that nurses have high adherence to the guidelines and are committed to quality care, it is also
important that health service managers ensure structural and organizational conditions in health services to offer safe care to
patients.
Although in compliance with the recommendations, health services organize strategies to improve clinical practice based on
their realities. Adaptation of protocols was observed, such as the Hand Hygiene Protocol of patients with 2% chlorhexidine towels
[24]. In general, however, studies evaluated not only hand hygiene but also a daily bath with chlorhexidine. Regarding HAIs, a meta-

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Research & Reviews: Journal of Nursing & Health Sciences
analysis allowed to suggest that the daily bath of ICU patients with chlorhexidine reduces the risks [43]. With regard to CLABSI, the
evidence also supports this indication [44].
Regarding the maintenance of catheters related to dressing changes, in the literature consulted, the studies were directed to
evaluations of nursing care technologies, especially the dressing of the insertion site [28-30]. Care related to changing dressings
of the insertion site of catheters in Brazil is the exclusive responsibility of nurses in the ICU. Including patient guidance on the
procedure, prediction of materials with systematic analysis of the necessary and available resources, and assessment of the
individual needs of the patients, which are steps contemplated within the planning of the nursing care. Nursing care can be
divided into activities relevant to the preparation of the patient and to the preparation of the procedure; dressing and disposal of
materials; and registration of the procedure [45].
No studies were identied with nurses' care for the patient, directed at the time of insertion or catheter removal. With
regard to the CVC removal, nurses work to prevent complications that may occur in the act of catheter removal or later, after the
procedure. The occurrence of adverse events during the scheduled removal of the CVC is uncommon [46,47]. However, when they
occur, these outcomes have a high degree of clinical importance, being in some cases fatal [46,47].
The nursing care include: to placed patients in the supine position, or in the Trendelenburg position to prevent air embolism
[46,48]; to educate the waltz maneuver in situations where the patient is able to cooperate; or to remove the catheter during the
patient’s active expiration [46,48]; to interrupt the CVC removal due to the occurrence of physical resistance and request evaluation
by an intensive care physician [48]; to apply digital compression to the ostium immediately for ve minutes to ensure hemostasis,
and to prevent the entry of blisters [46,48]; to ensure the patient supine position for 30 minutes after CVC removal [46,48]; after
stabilization, apply a sterile fully occlusive adhesive cover for 24 hours or longer (72 hours) with regard to ensuring hemostasis
[48]. Although there is no consensus about the duration of the occlusive dressing, procedures should be planned with a view to
minimizing the risk of air embolism, pneumothorax, and secondary hemorrhage [48].
Critical patients require that the conduct of health services is safe, as well as the care provided by professionals, based on
high-quality evidence. The overall quality assessment of the methods applied in the studies indicated a very low level of quality
of the evidence, according to the GRADE applied to the set of studies. For this level of quality of evidence, less condence is
attributed to the estimated effect generated, given the possibility of difference in the effect when results are generated from
studies with rigorous methods [18].
Research with a high level of evidence is required in the context of health care, especially to support therapies for critically
ill patients, given the vulnerabilities and complexity of the level of health care. Randomization, initially, corroborates a high level
of quality of evidence for RCTs [18,49]. It occurs in the methods of these studies and ensures protection against confounding of
prognostic factors between the compared groups (control and intervention) [49]. Randomized clinical trials are therefore used to
insert evidence-based practices, being this study design recommended to be used by nurses in clinical research to assess the
effects of nursing care on patients.
CONCLUSION
In this study, evidence was found that nursing care in the ICU reduces adverse events related to patient safety when using
CVC. However, in the results obtained from the analyses applying GRADE, the evidence was classied as having very low quality.
These ndings are mainly due to the study design and the content described in the method of the analyzed articles. Also, the fact
that the evidence was very low quality may be associated with the low number of randomized clinical studies. In addition, the
nursing care presented in the analyzed articles was restricted to maintaining the CVC with regard to reducing BSI, local reaction,
and dressing xation. The results of this review are contributions to the clinical practice of nurses and managers of highly complex
services. In the case of institutions that carry out partnerships for the development of research, it is recommended that the design
is of the randomized clinical trial type, and with planning and development with a low level of bias and a high level of evidence.
CONCESSIONS AND FINANCING
This is supported by Coordination for the Improvement of Higher Education Personnel (CAPES), Brazil, Finance Code, 001.
REFERENCES
1. Roque KE, Tonini T, Melo ECP. Adverse events in the intensive care unit: Impact on mortality and length of stay in a prospective study. Cad
Saude Publica. 2016;32:14.
2. Takashima M, et al. Complication and failures of central vascular access device in adult critical care settings. Critical Care Med. 2018;46:12.
3. Brazil. Ministry of Health, Ordinance No. 529, Institutes the National Patient Safety Program (PNSP). 2013.
4. Silva AM, et al. Practical guidelines for infusional therapy. INS Brasil. 2018;3:1-127.
5. Furuya EY, et al. Central line-associated bloodstream infection reduction and bundle compliance in intensive care units: a national study.
Infect Control Hosp Epidemiol. 2016;37:6.

10
J Nurs Health Sci | Volume 10 | Issue 5 | December, 2020
Research & Reviews: Journal of Nursing & Health Sciences
6. Lee KH, et al. Effect of central line bundle compliance on central line-associated bloodstream infections. Yonsei Med J. 2018;59:7.
7. Resar R, et al. Using care bundles to improve health care quality. IHI Innovation Series white paper. Inst Healthcare Improv. 2012;2:1-18.
8. O'Grady NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Inf Contr. 2011;39:35.
9. Adler L, et al. Impact of inpatient harms on hospital nances and patient clinical outcomes. J Patient Safety. 2018;14:7.
10. Lambert P, et al. Reducing acute kidney injury due to contrast material: How nurses can improve patient safety. Critical Care Nurse.
2017;37:14.
11. Lee A, et al. Are high nurse workload/stafng ratios associated with decreased survival in critically ill patients? A cohort study. Ann Int Care.
2017;7:10.
12. Shamseer L, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: Elaboration and explanation.
BMJ. 2015;350:26.
13. Jesus SC, et al. Nurse care related to central venous catheter insertion, maintenance and removal: systematic review. PROSPERO. 2020;20:7.
14. Eriksen MB and Frandsen TF. The impact of patient, intervention, comparison, outcome (PICO) as a search strategy tool on literature search
quality: a systematic review. JMLA. 2018;106:11.
15. Ouzzani M, et al. Rayyan - A web and mobile app for systematic reviews. System Rev. 2016;5:11.
16. Conger AJ. Kappa and rater accuracy: Paradigms and parameters. Edu Psychol Meas. 2016;77:29.
17. Lands JR and Koch GG. The measurement of observer agreement for categorical data. Biomet. 1977;33:16.
18. Zhang Y, Akl EA, Schünemann HJ. Using systematic reviews in guideline development: the GRADE approach. Res Synth Methods. 2018;10:18.
19. Sterne JAC, et al. ROBINS-I: A tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:8.
20. Sterne JAC, et al. RoB 2: A revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:9.
21. The Cochrane Collaboration. Rev Man. Version 5.4. 2020.
22. Moher D, et al. The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med.
2009;6:7.
23. McGuinness LA, Higgins JP. T. Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments.
Res Synth Method. 2020;20:8.
24. Fox C, et al. Use of a patient hand hygiene protocol to reduce hospital-acquired infections and improve nurses' hand washing. AMJ Critical
Care. 2015;24:9.
25. Kahn JM, et al. Impact of nurse-led remote screening and prompting for evidence-based practices in the ICU*. Critical Care Med. 2014;42:9.
26. Kaya H, et al. The effect of nursing care protocol on the prevention of central venous catheter-related infections in neurosurgery intensive
care unit. App Nurs Res. 2016;32:5.
27. Munoz-Price LS, et al. Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections.
Critical Care Med. 2012;40:6.
28. Pedrolo E, Danski MTR, Vayego SA. Chlorhexidine and gauze and tape dressings for central venous catheters: a randomized clinical trial.
Latin Amj Nurs. 2014;22:8.
29. Pedrolo E, et al. Infection, local reaction and poor xation of dressings for central venous catheter. Acta Paulista De Enf. 2014;27:6.
30. Pfaff B, Heithaus T, Emanuelsen M. Use of a 1-piece chlorhexidine gluconate transparent dressing on critically ill patients. Critical Care Nurs.
2012;32:6.
31. Sahni N, et al. Effect of intensive education and training of nurses on ventilator-associated pneumonia and central line-associated
bloodstream infection incidence in intensive care unit at a tertiary care center in North India. Indian J Crit Care Med. 2017;21:4.
32. Yazici G and Bulut H. Efcacy of a care bundle to prevent multiple infections in the intensive care unit: A quasi-experimental pretest-posttest
design study. App Nurs Res. 2018;39:7.
33. Sichieri K, et al. Central line bundle maintenance among adults in a university hospital intensive care unit in São Paulo, Brazil: a best practice
implementation project. JBI Data Sys Rev Implem Rep. 2018;16:20.
34. Silva JA, et al. Breakdown of complications related to the use of central venous catheters in intensive therapy units. Bioscience J. 2018;34:8.
35. Wallace MC and Macy DL. Reduction of central line-associated bloodstream infection rates in patients in the adult intensive care unit. J Infu
Nurs. 2016;39:9.
36. Caneld C and Galvin S. Bedside nurse acceptance of intensive care unit telemedicine presence. Crit Care Nurs. 2018;36:5.
37. Jamous S, et al. Achieving a zero central line-associated bloodstream infection rate in 4 critical care units in Lebanon. J Infu Nurs. 2019;42:5.
38. Aloush SM and Alsaraireh FA. Nurses' compliance with central line associated blood stream infection prevention guidelines. Saudi Med J.
2018;:39:7.

11
J Nurs Health Sci | Volume 10 | Issue 5 | December, 2020
Research & Reviews: Journal of Nursing & Health Sciences
39. Crivelaro N, et al. Adhesion of nursing to the blood current infection protocol. J Nurs UFPE online. 2018;12:2361-2367.
40. Barbosa CV, et al. Knowledge of the nursing team on care with central venous catheter. J Nurs UFPE online. 2017;11:8.
41. Dantas GD, et al. Nursing team adherence to measures for prevention of blood current infections. J Nurs UFPE online. 2017;11:9.
42. Karapanou A, et al. Failure of central venous catheter insertion and care bundles in a high central line–associated bloodstream infection
rate, high bed occupancy hospital. Amj Inf Control. 2020;48:7.
43. Huang HP, et al. The efcacy of daily chlorhexidine bathing for preventing healthcare-associated infections in adult intensive care units.
Korean J Intern Med. 2016;31:12.
44. Shah HN, et al. Bathing with 2% chlorhexidine gluconate evidence and costs associated with central line–associated bloodstream infections.
Critical Care Nurs Quarterly. 2016;39:9.
45. Gomes MLS, et al. Assessment of short-term central venous catheter dressing practices. Revista Enf UERJ. 2017;25:7.
46. McCarthy CJ, et al. Air embolism: practical tips for prevention and treatment. J Clin Med. 2016;5:14.
47. Eum DH, et al. Cerebral air embolism following the removal of a central venous catheter in the absence of intracardiac right-to-left shunting:
a case report. Med. 2015;94:4.
48. Ingram P, Sinclair L, Edwards T. The safe removal of central venous catheters. Nurs Stand. 2006;20:5.
49. Schünemann HJ, et al. GRADE guidelines: 18. How ROBINS-I and other tools to assess risk of bias in nonrandomized studies should be used
to rate the certainty of a body of evidence. J Clin Epidemiol. 2019;111:10.