Infection Control & Hospital Epidemiology
The primary outcomes were CVC use and CLABSI rate. Measure- ments of CVC use vary, including the percentage of patients with (unnecessary) CVCs before and after the intervention versus the total (or mean) number of days of CVC use before and after the intervention. CLABSI rates are mainly reported as the proportion of patients who developed CLABSIs or as CLABSI episodes per 1,000 CVC days before and after the intervention. The secondary outcomes of interest include compliance with the intervention, catheter-related noninfectious complications, hospital-related out- comes (LOS and mortality of patients), and cost.
Data sources and searches
Four electronic databases were searched from inception until August 28, 2018: PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), and the Cumulative Index to Nursing and Allied Health (CINAHL). We also scanned the reference lists of all included articles and relevant reviews identified through the search. We did not apply a language restriction. The search strategy included terms relating to or describing the population, intervention, and outcomes. Further details of the search strategies are available in the Supplementary Materials online.
Data extraction and analysis
Titles, abstracts, and full-text screening, as well as data extraction, were performed independently by the 2 review authors (Xiong, Chen). Any disagreement was settled by discussion. A standardized, pilot-tested form was utilized to extract data from the included studies for assessment of study quality and key characteristics of the identified studies. Extracted information included author, publica- tion year, country, study design, characteristics of participants, follow time, details of the intervention, and information for assessment of the risk of bias. The methodological quality of the studies was evaluated using various methods depending on the study design. The quality of randomized controlled trials (RCTs) was
assessed using the Cochrane Review Manager (Revman) version 5.3 ‘Risk of bias’ table software.12 The following 7 standard criteria were used to assess themethodological quality of RCTs: (1) sequence generation, (2) allocation concealment, (3) blinding of participants and researchers/healthcare providers, (4) blinding of outcome assessors, (5) methods of addressing incomplete outcome data, (6) selective reporting of outcomes, and (7) other possible sources of bias. For each quality criterion, we assessed and graded the study as low risk, high risk, or unclear risk according to recom- mendations for judging the risk of bias provided in chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions.12 The quality of quasi-experimental studies (QESs) was assessed
using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Quasi-Experimental Studies (nonrandomized experimental studies).13 The checklist included 9 items: (1) clear cause and effect, (2) similar participants, (3) similar treatment, (4) whether there is a control group, (5) multiple measurements of the outcome both before and after the intervention, (6) complete follow-up, (7) outcomes measured in the same way, (8) outcomes measured in a reliable way, and (9) appropriate statistical analysis. Each criterion was graded as yes, no, unclear, or not applicable according to the explanation for the critical appraisal tool for QESs.13 The quality of observational studies was assessed using the Newcastle-Ottawa Scale (NOS),14 which has been used by review groups at the Cochrane Collaboration to evaluate the quality of
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observational analytical studies. This 8-itemtool uses a star systemto assess methodological quality across 3 categories: the methods for selecting the study groups; their comparability at baseline; and the ascertainment of the outcome of interest. Scores range from 0 to 9 stars. Data verification and analysis were conducted by one author (Xiong), and a descriptive analysis was performed.
Results Search results
In total, 1,892 unique citations were retrieved through the literature search; of these, 14 studies were included in this review (Fig. 1). The study selection procedure is described below.
Characteristics of included studies
Morata,18 Swaminathan,20 and Reeves19 included only peripherally inserted central venous catheters (PICCs). Grady27 defined the CVCs as nontunneled; nondialysis catheters in jugular, subclavian, or femoral veins; or PICCs. Only 5 studies (35.7%) mentioned the definition of CLABSI,15,16,20,21,25 and they all used the Centers for Disease Control and Prevention/National Healthcare Safety Network (CDC/NHSN) criteria. The sample size of included studies varied. Most studies reported sample size in terms of number of patients, ranging from
A comprehensive description of the studies is summarized in Table 1. The 14 included studies were published between 2010 and 2018 and were performed in the United States,15–24 Canada,25,26 France,27 and Thailand.28 Of the eligible studies, 1 (7.1%) was a cluster RCT,28 4 (28.6%) were cohort studies,22–24,26 and 9 (64.3%) were QESs, including 5 before-and-after QESs,15,16,18,25,27 3 inter- rupted time-series studies,19–21 and 1 pilot study.17 These studies were all conducted in adult departments; all patients were ≥18 years old. Only 2 studies included all inpatients and observation patients.16,18 Most studies included only a specific department: 5 studies implemented the intervention in the medical and/or surgical wards,19,20,23,25,28 2 studies were performed in the emergency departments,22,24 and 5 studies focused on patients in intensive care units only.15,17,21,26,27 Only 4 studies (28.6%) specified the type of CVC used.18–20,25
Fig. 1. Flow chart of study selection procedure. Note. CENTRAL: The Cochrane Central Register of Controlled Trials; CINAHL: Cumulative Index to Nursing and Allied Health.
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