Date of Award

Spring 2023

Project Type


College or School




Departments (Collect)


Program or Major

Evidence Based Nursing

Degree Name

Master of Science

First Advisor

Pamela Kallmerten


Introduction: At a large academic healthcare facility in the northeast a Gap Analysis was conducted finding quality improvement opportunities for central line associated blood stream (CLABSI) prevention in critically ill patients. Review of literature reveals the use of minocycline-rifampin impregnated (MNRI) central venous catheters (CVCs) as being an effective intervention in CLABSI prevention.

Methods: Several assessments were conducted regarding the implications of updating the facilities practice to reflect this evidence including AHRQ Gap Analysis Tool, a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis, Stakeholder Feedback, and Resource Allocation.

Results: Facilitators and barriers were identified in implementing this practice change as the facility. Themes were identified based on stakeholder feedback, and important multidisciplinary team members were identified in being required to assist in practice change.

Discussion: Implementation of this practice change is feasible at this facility and engagement of more key stakeholders will be necessary to progress. The Gap Analysis provided useful data in planning this practice change and is recommended to be used as a tool when implementing change.