Analysis of Central Line Cares in a Hospital Setting

Central line-associated infection (CLABSI) accounts for approximately 14% of healthcare associated infections (Wood, 2017). CLABSI is an avoidable, yet very serious condition, and can be responsible for high mortality in patients (Conley, 2016). One of the key practices involved with reducing CLABSI is by standardizing practice by implementing "evidence-based policies associated with measurable improvement in patient outcomes" (Conley, 2016, para. 12). In addition, patients with central lines are often very observant of the care performed, and standardizing care across facilities will help minimize variations in care (Weingart et al., 2014). The hospital where this project was conducted is seeking to standardize central line care between two campuses. The purpose of this project is to address inconsistent timing in central line care and designing protocols to include the following: Standardize central line dressing change from every Tuesday to once a week to align with other affiliated hospital's current practice; Add a best practice alert (BPA) to alert staff when the dressing change is due; Standardize tubing changes/needleless connector changes to also align with other affiliated hospital's current practice; Provide staff education on the new policy; Update policy at the go-live date. Incorporating this protocol will decrease the likelihood that a patient would have the central line dressing changed sooner or later than indicated.

ANALYSIS OF CENTRAL LINE CARES 1 Analysis of Central Line Cares in a Hospital Setting Catherine Turcotte, RN BSN University of Utah May 10, 2022 In partial fulfillment of a Master of Science degree College of Nursing Major: Nursing Specialty: Nursing Informatics ANALYSIS OF CENTRAL LINE CARES 2 Introduction Central line-associated infection (CLABSI) accounts for approximately 14% of healthcare associated infections (Wood, 2017). CLABSI is an avoidable, yet very serious condition, and can be responsible for high mortality in patients (Conley, 2016). One of the key practices involved with reducing CLABSI is by standardizing practice by implementing “evidence-based policies associated with measurable improvement in patient outcomes” (Conley, 2016, para. 12). In addition, patients with central lines are often very observant of the care performed, and standardizing care across facilities will help minimize variations in care (Weingart et al., 2014). The hospital where this project was conducted is seeking to standardize central line care between two campuses. The purpose of this project is to address inconsistent timing in central line care and designing protocols to include the following: • Standardize central line dressing change from every Tuesday to once a week to align with other affiliated hospital’s current practice. • Add a best practice alert (BPA) to alert staff when the dressing change is due. • Standardize tubing changes/needleless connector changes to also align with other affiliated hospital’s current practice. • Provide staff education on the new policy. • Update policy at the go-live date. Incorporating this protocol will decrease the likelihood that a patient would have the central line dressing changed sooner or later than indicated. For example, under the past protocol a patient may have their central line inserted on a Sunday. They would then have the dressing changed in either two days or nine days. Under the new protocol, nurses will change the dressing the next Sunday, and every 7 days following unless there is reason to change it sooner. The decision to change a dressing is at risk to be subjective as the decision relies on the clinical judgement of a nurse. ANALYSIS OF CENTRAL LINE CARES 3 These proposed changes align with the current evidence for best practice and prevention of CLABSI. The Centers for Disease Control and Prevention (CDC) recommends replacing dressings on central venous catheter (CVC) sites “no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed” (CDC, 2011, para. 6). The 2016 Infusion Therapy Standards of Practice recommends dressings changed at routine intervals and immediately if “dressing integrity becomes damp, loosened, or visibly soiled, or if moisture, drainage, or blood are present under the dressing” (Gorski, 2017, pg. 17). Every time a CVC is accessed, whether to administer fluids or dressing changes, it is an opportunity to introduce microorganisms (Joint Commission, 2013). Lapses in proper infection control techniques can lead to postinsertion infection episodes. The most common lapse involved improper management of caps and site dressings (Joint Commission, 2013). The Joint Commission’s recommendations align with the CDC in recommending central line dressing changes every seven days, with no specification of the day of the week. The other component of this process is performing tubing changes, along with needleless connectors, every 96 hours and as needed. The previous policy required changing tubing and caps every Tuesday and Friday and PRN. The new policy aligns with the CDC recommendation to “Replace disposable or reusable transducers at 96-hour intervals. Replace other components of the system (including the tubing, continuous-flush device, and flush solution) at the time the transducer is replaced” (CDC, 2011, para. 17). Duncan et al. (2018) found that it is not only safe, but also economical to change all IV tubing every 96-hours—as long as the tubing is properly protected (Duncan et al., 2018). With these proposed changes, it is critical that clinicians maintain current best practice such as maintaining sterile technique during dressing changes. Some of the practices that put patients in danger is seemingly small actions such as failure to properly disinfect caps and failure to cap the tubing. One critical component of the new process would be the addition of Best Practice Alerts (BPA’s) to the patient’s chart alerting the clinician to perform central line care. Best practice ANALYSIS OF CENTRAL LINE CARES 4 alerts also known as “practice advisories” are implemented in the Epic electronic health record (EHR) to alert clinicians to complete tasks. Practice advisories are based on algorithms built into the EHR which will cause an alert to be displayed when the clinician performs a task such as opening the patient chart (Riaz & Krasuski, 2016). Clinicians should keep in mind that BPA’s should be viewed as a supportive rather than a decision-making tool (Riaz & Krasuski, 2016). An email survey showed that the majority of clinicians at the hospital favored the use of BPA’s with the standardization of central line care. The importance of staff education cannot be understated. Kapil et al. (2020) conducted a study in a neurointensive care unit setting, and showed the importance of continuous education and training for CABSI prevention. An education plan is in place to deliver to users prior to the going-live date with the new procedures. This plan includes: • Include dressing change times for patients when giving shift report. • Use of flyers and a safety campaign. • Track the education each staff member receives. • Write the date of the dressing change on the central line dressings. The final component of the plan is to use stickers to label tubes. This portion still needs to be clarified as there is debate on how to align current practice and best practice. Because of the timeframe of the central line care standardization project, and the fact that it is still in the early stages of assessment and planning, this author will be analyzing/documenting the current workflow, and doing the same process with the future, or ideal, workflow processes, as well as informing future intervention planning by workflow diagrams and staff input. This will be accomplished through the collection and analysis of data. Goals and Objectives The short-term goals of this study are evaluate workflow process and clinical staff belief’s regarding the current workflow process and the long-term goals are to create a single ANALYSIS OF CENTRAL LINE CARES 5 workflow process between the campuses of one hospital system. With these goals in mind, the following objectives were developed: 1. To describe baseline characteristics of procedures and quality metrics in selected units. 2. To describe the current workflow and expected changes after implementing the planned interventions. 3. To assess nursing perspectives related to the new procedures for CVC care. Staff This protocol change will directly impact workflow for clinical nurses as well as possibly impact the occurrence of CLABSI. The ultimate goal of the change is to both improve patient outcomes and improve the workflow for clinical nurses. The current policy at the hospital states that both RN’s and LPN’s can change central line dressings, tubing, and injection caps. The nurse to patient ratio is approximately 1:4 in the acute care setting, and 1:2 in the ICU. Nurses are responsible for assessing the patient for the presence of a central line, completing all care, reporting adverse reactions to the physician, and documenting in the patient’s chart. Nurses on the specified units may be directly observed and/or interviewed in order to create the workflow processes. Methods Setting The setting of this project was three units at two different campuses of a single hospital in order to draw comparisons between the effects of different CVC care policies of each hospital. Two of the units (unit A and unit B) were at Campus 1 and one unit (unit C) is at Campus 2. These units were selected with guidance from the preceptor of this project. The campuses use a system of medical software called Epic. There were no current methods at the hospital for Epic to create a list of patients who have central lines. In order to compile a list, this author manually accessed each patient chart to look for indicators of a central ANALYSIS OF CENTRAL LINE CARES 6 line. Indicators were found by examining the worklist, chart notes, and flowsheets. This author was given access to Epic for this project. This author’s contributions to the study were done both in-person and remotely. CLABSI Data CLABSI is a potentially lethal infection that can be a result of mismanagement of central lines (Joint Commission, 2013). Reducing and eliminating CLABSI can be a result from this intervention. In fact, campus-wide CLABSI rates differed between the two campuses. The CLABSI rate in campus 2, where CVC dressings are changes every day of the week, was 16% lower than the rate reported for Campus 1 where CVC dressings are changed once a week on Tuesdays. Workflow Assessment The care processes relevant central line dressing changes were gathered from clinical and leadership nursing personnel. Both scheduled/routine and PRN “as needed” cares were documented. Table 2 shows a summary of the current workflow and the proposed/future workflow. Table 1. Workflow summary. Current Workflow Future Workflow Dressings changed every Tuesday and PRN. Dressings will be changed every 7 days (regardless of day of the week) and PRN. Tubing changed every Tuesday, Friday and PRN. Tubing will be changed every 96 hours (regardless of day of the week) and PRN. Baseline (Quantitative) Assessment A chart review was conducted on three different days. As part of the review process, selected units in Epic were examined for data concerning central line cares. An important fact taken into consideration is Campus 2 had a large number of patients with implanted ports which are categorized as a CVC. ANALYSIS OF CENTRAL LINE CARES 7 The quantitative data included a chart audit, data analysis, and documentation of the current and future workflow processes. Three units were examined in Epic for the following: • Document percentage of patients in each unit with a current or previous CVC. • Document the number of and frequency of dressing changes. • Determine which percentage of dressing changes were early, on time, or late. Qualitative Data The qualitative data consisted of a “listening tour” on one of the units. Interviews of clinical and leadership nurses were conducted and actual CVC dressing changes were observed. The questions guiding the listening tour consisted of the following: 1. Have you heard of the proposed change to dressing changes weekly instead of every Tuesday? This change aligns with best practice (CDC & Joint Commission). 2. How do you think this change will impact patient care and health outcomes? 3. What concerns do you have regarding this proposed change? 4. Does it surprise you that most CVC dressings were actually changed early in the chart review? (71% of CVC dressings on this unit were changed early, equating to an average of 4 days early). The nurses’ responses were unofficially collected through written notes and analyzed for themes and content. Ethics Statement While the outcomes of this project will have a major effect on patient care, the intent is quality improvement in patient care by aligning with best practices. This will be accomplished by enhancing the EHRs ability to alert clinicians to CVC dressing changes and evaluation of clinician’s adherence to a previously developed process of care, thus IRB approval was not attained. ANALYSIS OF CENTRAL LINE CARES 8 Results Significant Findings One of the biggest and unexpected findings of the data collection and analysis portion of this study was that CVC dressings are changed early on all units of both campuses of the hospital. Campus 1 did have a higher rate of early dressing changes than Campus 2. If 35% of the 71% of early dressing changes on Unit A were theoretically early because as a result of the current practice of changing dressings on Tuesday, there should be a significant decline in the rate of early dressing changes post-implementation of weekly dressing changes. With organizations such as the CDC and Joint Commission making clear recommendations to only change dressings once per week, unless the dressing integrity is compromised or the dressing is soiled, finding the root cause of early dressing changes is of critical importance. During the observation of Unit A on Campus 1, it was evident of the extreme mental energy required by nurses caring for acute patients. In addition, it should be brought to attention the potentially large impact that caring for patients in the midst of the COVID-19 pandemic over the past two years has had on clinicians. It is still unknown how these stressful conditions have impacted clinicians’ decision-making processes and overall patient care. As a nurse, this author can reasonably infer that if an acute care nurse believes that a CVC dressing needs to be changed sooner than 1 week, they are not going to wait to do this. While the clinician may have the best intentions, according to the existing research this practice can lead to overtreatment and higher costs for the patient. Baseline Characteristics of Procedures and Quality Metrics Chart Review of Dressing Change Frequency A significant difference was seen between the dressing change frequency in Campus 1, which has the current protocol of changing CVC dressings on Tuesday, compared to Campus 2 where CVC dressings are changed once weekly. Campus 1 had a higher rate of early dressing changes than Campus 2. ANALYSIS OF CENTRAL LINE CARES 9 The most significant findings was that on Unit A of Campus 1, 71% of CVC dressings were changed early. It is estimated that 35% of all the early dressing changes may have been completed early because of the requirement to change the dressing on Tuesday. In comparison, only 44% of all surveyed dressing changes were early at Unit C of Campus 2. CVC dressings were changed on average 4 days early on Unit A of Campus 1, 1.2 days early on Unit B of Campus 1 and 3.1 days early on Unit C of Campus 2 (out of all early dressing changes. 35% of all early dressing changes on Unit A and 50% of all early dressing changes on Unit B were on a Tuesday. It can be inferred that a significant portion of early dressing changes occur because of the current protocol at Campus 1 of changing CVC dressings on Tuesdays. These results are summarized in Figure 2. When analyzing these results, it is important to take into consideration that Unit C of Campus 2 had a larger sample size and also had patients with implanted ports, which were considered a CVC for this study. Campus 2 has a larger number of cancer patients while Unit A and B of Campus 1 tend to have a larger number of cardiac patients. ANALYSIS OF CENTRAL LINE CARES 10 Table 3. Description of Central Line Dressing Change Status Based on Chart Review Campus 1: Unit A Campus 1: Unit B Campus 2: Unit C 29 10 25 12 (41%) 4 (40%) 13 (48%) 24 9 61 Dressing changes were late 0 (0%) 0 (0%) 11 (18%) Dressing changes are ‘on time’ 7 (29%) 1 (11%) 23 (38%) Dressing changes were early 17 (71%) 8 (89%) 27 (44%) 4 1.2 6 (35%) 4 (50%) Number of patient charts surveyed Patients had current or previous CVC Total number of dressing changes for all patients with a CVC Among early dressing changes, average number of days early Proportion of early dressing changes due to the Tuesday dressing change schedule 3.1 N/A ANALYSIS OF CENTRAL LINE CARES 11 Figure 1. Timing of Dressing Changes on Unit A/Campus 1 7 3 3 2 1 0 DAYS 1 DAY (ON TIME) EARLY 2 DAYS EARLY 1 3 DAYS EARLY 4 DAYS EARLY 5 DAYS EARLY 6 DAYS EARLY Figure 2. Timing of Dressing Changes on Unit B/Campus 1 3 2 1 1 1 1 0 0 DAYS (ON TIME) 1 DAY EARLY 2 DAYS EARLY 3 DAYS EARLY 4 DAYS EARLY 5 DAYS EARLY 6 DAYS EARLY Figure 3. Timing of Dressing Changes Unit C/Campus 2 23 6 0 DAYS (ON TIME) 1 DAY EARLY 2 2 DAYS EARLY 6 3 DAYS EARLY 3 4 DAYS EARLY 7 5 DAYS EARLY 6 DAYS EARLY ANALYSIS OF CENTRAL LINE CARES 12 Workflow Assessment Documentation of the workflow can provide a “roadmap” for the project. This author used Word, Excel, Lucid Chart and other technological tools to diagram the workflow. The results of documenting both current and future workflow processes showed that there was not a significant change pre- and post-intervention except, with the exception for the day of the week the dressing is changed and the addition of the BPA. Almost all assessment and intervention processes completed by the nurse remain the same. The current workflow summary is shown in Figure 4, and the future workflow summary is shown in Figure 5. ANALYSIS OF CENTRAL LINE CARES Figure 4. Current Workflow. Figure 5. Future Workflow. 13 ANALYSIS OF CENTRAL LINE CARES 14 Qualitative Data Interviews and shadowing of five different nurses, using the standardized questions (as summarized above in the methods) guided the qualitative data collected. Nurses stated the change in protocol would be a “good thing” as long as the dressing changes were “remembered and not forgotten.” For example, one nurse commented that “with practice and reminders” this change is possible. Multiple nurses also commented on discussing the CVC dressings more frequently during shift reports. This is already standard for peripheral IVs. Nurses noted this will be especially important post-implementation when dressing changes can occur on any day of the week. Nurses noted there were many ways that Epic could support the change, such as a comment from a nurses discussing the possibility of adding a “sticky note” in the patient’s chart of when the CVC dressing was last changed. A nurse supervisor also recognized the need for Epic to more efficiently display information concerning CVC care during chart audits. They noted Epic currently does not have the ability to display the date the CVC dressing was last changed on a list of multiple patients. Therefore, each patient’s chart needs to be opened to find this documentation. During this author’s chart audit of this specific unit there were no late dressing changes noted. As discussed with the nurses, staff compliance with dressing changes could still be a potential issue, especially post-intervention. The supervisor brought up some ways to motivate staff members that may be less compliant could involve monthly scorecards and pulling statistics, which Epic could also help support in the future by having the capabilities of running reports related to CVC cares. This author discussed with nurses that 71% of the surveyed CVC dressings were changed early. The nurses were not surprised by this statistic, and verbalized that this change would “help spread out the work.” All nurses seemed confident in their own skills and that of other nurses to do the actual dressing change. ANALYSIS OF CENTRAL LINE CARES 15 Table 3. Summary of nurse feedback on Unit A. Questions: Comments/Observations: Have you heard of the proposed change to dressing changes weekly instead of Tuesday? This change aligns with best practices (CDC & Joint Commission). All nurses had heard of the proposed change. How do you think this change will impact patient care and health outcomes? The change will be a good thing as long as dressing changes are remembered and not forgotten. With practice and reminders, this is possible. This will be a positive change in patient care. Less frequent dressing changes may help with skin issues and skin breakdown that can occur when dressings are changed more often than needed. I will also address highcost issues. Management needs more effective tools in Epic to conduct chart audits. What concerns do you have regarding this proposed change? The biggest concern is that other nurses will have trouble keeping track of dressing changes on all days of the week. It may be helpful to put a reminder when the dressing needs to be changed on a treatment sticky note in the patient’s chart. This should also be discussed during the bedside report. Does it surprise you that most CVC dressings were actually changed early in the chart review (71% of CVC dressings on this unit were changed early, equating to an average of 4 days early). Nurses were not surprised by this statistic. This change in protocol will hopefully eliminate having to make the judgment call of either changing a dressing extremely early or not changing it and having it potentially changed late. Other Observed a supervisor change a PICC dressing. Procedure took approximately 15 minutes. Limitations The limitations of both the qualitative and quantitative data collection processes are relatively small sample sizes. In order to get a true estimate of the frequency of dressing changes at each hospital, an in-depth chart review would be needed. Another limitation was that ANALYSIS OF CENTRAL LINE CARES 16 many patients at Hospital 2 had implanted ports. These may have a higher likelihood of on-time dressing changes due to existing protocols of accessing and de-accessing the ports. To better understand the impact of this change on nurses, additional units at the hospital would need to be observed and interviewed. Shadowing a unit at Hospital 2 would have provided a perspective of what post-implementation would look like at Hospital 1. This was not possible due to the time constraints of this project. Discussion Informatics Perspective One of the critical questions from a nursing informatics standpoint is, “How can Epic be used to assist nurses in being compliant with central line cares?” The entire workflow process depends on nurses charting completely and accurately in the clinical setting. If a nurse fails to chart that a new patient has a central line, the orders for the related care will not be entered. Once the care is completed, it needs to be documented in the chart or else the BPA and worklist task will continue to show up. There is uncertainty about how compliance will be measured. If Epic is able to generate reports related to central line care, this would be beneficial to the evaluation process. A report could theoretically track what percentage of patients had central line dressings and tubing changed on time, and if it was documented correctly. If a report cannot be generated, the rate of compliance may have to be tracked manually. There may be capabilities of the EHR that can help support CVC care that have not been explored or utilized. It is the role of the nurse informaticist to be familiar with the capabilities of the EHR, and find out if changes can be made to help better support clinicians. Summary The data collection and analysis process did support the proposed EBP/CQI change by showing that a significant percentage of CVC dressings are being changed early due in part to the policy of changing all central lines on a Tuesday rather than every 7 days. Lack of ANALYSIS OF CENTRAL LINE CARES 17 compliance, or late dressing changes, did not come up in the chart review of Hospital 1. Hospital 2 had a lower percentage of early dressing changes and a higher percentage of ontime (every 7 days) dressing changes. Documenting the workflow showed that while this process change is significant, many of the existing workflow processes will remain the same. During the “listening tour” the overall response from staff regarding the proposed QI change was positive. Once staff adapt to this change it could lead to less work and also be very beneficial to patient care outcomes. One nurse remarked how this change could actually lead to less skin breakdown and reduced cost to the patient through eliminating unnecessary dressing changes. This study revealed that the current workflow and EMR documentation did not include the nurse’s clinical reasoning behind why CVC dressings are changed early other days of the week than Tuesday. Potential reasons discussed with nurses were the dressing getting wet in the shower and blood at the site. With the implementation of weekly dressing changes, early and PRN dressing changes and clinical reasoning for early changes should become clearer, and the causes of these dressing changes can be addressed through patient and staff education, along with recommendations for changing how these dressing changes are documented in the HER. Proposed Evaluation Plan A proposed evaluation plan should focus on how clinicians comply to the documentation of the new process. Therefore, the short-term goals of this project related to compliance and correct documentation by staff. Staff feedback is also part of the final evaluation plan. Staff feedback has already been captured using an emailed survey. Other methods to measure feedback, especially related to the education portion, could include emailed and written surveys, meetings, ect. A follow-up survey after the go-live date would also be an effective evaluation method. ANALYSIS OF CENTRAL LINE CARES 18 Since the overall goal of any EBP/CQI project in a healthcare setting always involves patient outcomes, decreasing and preventing CLABSI is a key outcome to measure to the process change. There are different ways this can be measured, including chart reviews and examining hospital readmissions. CLABSI cases are also tracked by the hospital’s larger organization. The Joint Commission developed a formula for measuring the CLABSI rate by dividing the number of CLABSI cases in each unit assessed by the total number of central linedays in each unit assessed and multiplying by 1,000. This will provide the CLABSI rate per 1,000 central-line days (Joint Commission, n.d.). Clinical Significance The clinical significance of the presence of a central line cannot be understated. When complications occur, it can lead to delayed recovery, an increased rate of hospitalizations, and significant morbidity (Ball & Singh, 2021). Many nurses in the qualitative phase of the study expressed in different words that their biggest concern was that dressing changes would be remembered by other nurses after the implementation of changing dressings every seven days for the patient instead of on Tuesday. A missed dressing change would both put the patient at risk and lead to an increased workload for already burdened clinicians. Just because late dressing changes were not seen in the chart review, does not mean they do not occur. Monitoring compliance will be especially important after the go-live date at campus 1. The plan to incorporate the BPA into the chart is one powerful way to address this concern. This author was able to join some workgroup meetings related to this project and realized that adding this specific BPA will be very complex from an IT standpoint. Some of the technological aspects of change in a clinical setting will likely be on the same level of complexity, however, if it supports clinicians and improves patient outcomes then these interventions can be justified by the healthcare institution. ANALYSIS OF CENTRAL LINE CARES 19 Recommendations for Nursing Practice The recommendations for nursing practice to address CVC care and particularly early dressing changes are: a. Encourage nurses document the reason for a PRN dressing change in the patent’s flowsheet. During the chart review, this author did not see any documentation on why dressings were changed early. The flowsheet does have the capability for charting this information, such as under the assessment of the CVC line. b. Providing education to staff during the annual CLABSI prevention training on when to change or not change a CVC dressing. Train supervisors to look for early dressing changes during chart audits, and address any concerns with staff. c. Additional patient education may be needed on CVC care to help prevent dressing integrity from being compromised. A patient may be unaware of the importance of not getting the CVC dressing wet. Some dressings may be changed unnecessarily early because of patient anxiety. For example, the patient may request an early dressing change because there is a small amount of blood at the site when changing the dressing is not justified according to the best practices outlined by the CDC and Joint Commission. Future Studies Because of the preliminary nature of the data findings, it remains to be seen how the results of this implementation will ultimately effect patient care and health outcomes. Patient anxiety may also be reduced through the standardization of care across campuses. This author concludes that future data collection in regards to CVC care at the hospital will be beneficial. Finding a way to generate reports in Epic related to central line care could be a secondary result of this process change. Future studies in this area could include a more in-depth chart review and qualitative data from actual patients in the hospital with CVC lines. ANALYSIS OF CENTRAL LINE CARES 20 Conclusion The major finding of this study that a significant portion of CVC dressings are changed early, rather than late, in the hospital setting demonstrates that one can go into a study expecting one result, only to have the data show otherwise. It was also significant that Campus 2 did have a lower CLABSI rate than Campus 1 over a period of several months and CVC dressings are changed early at a lower frequency than Campus 1. Even if the data had shown the opposite, it would not necessarily discount the intervention. Data analysis can be a complex process that can depend on the timeframe, methods used to analyze the data, and the availability of the data itself. One of the biggest strengths of this study was it started by examining best practices per the CDC before analyzing current practices in the hospital setting. It also included both quantitative and qualitative data. The quantitative data employed different methods of data and workflow analysis. In regards to the qualitative data, conducting a listening tour with semistructured interviews was an efficient way to gain feedback from multiple nurses without taking time away from patient care. Diagraming the current and future workflow was beneficial for gaining more understanding of the implementation. Even though there are variances in the steps pre and post-implementation, the overall larger process remains similar. ANALYSIS OF CENTRAL LINE CARES 21 References Ball , M., & Singh, A. (2021, September 29 ). Care of a Central line. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK564398/ Centers for Disease Control and Prevention (CDC). (2011). 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