Centeral Venous Infection

‘Use of Central Venous Catheter- Related Bloodstream Infection Prevention Practices’ The nursing profession continually strives for the evidence-based practice, which includes research studies, critiquing and synthesizing studies, and applying scientific evidence into the nursing practice. Thus critiquing research is an essential step toward basing the practice on empirical evidences. An intellectual critique is directed at the elements that are created rather than at the creator. The elements of intellectual critique of the research are described to assist in determining the quality of empirical evidence generated by the studies. An intellectual research critique is a careful, complete examination of a study to judge its strengths, weakness, logical links, meaning, and significance. A high quality study focuses on a significant problem, demonstrates sound methodology, produces credible findings, and provides a basis for additional studies done by other researchers (Burns& Groves, 2006). Critiquing a study involves the application of some basic guidelines to assist in finding answers for some questions.

They are: 1) what are the research problem significant? 2) What are the major strengths and weakness of the study? 3) Does the researcher use sound methodology? 4) Was the study results valid? 5) Is there any study replicated and what is the results comparison? Are there any implications to practical applications? (Burns & Groves, 2006). By answering these questions one can find the strengths, weakness, and validity, reliability and implications of the study to the practice. Critiquing research will manifest in the use of a variety in critical thinking skills and in the application of knowledge of the research process. The research critique process of a quantitative study includes four critical thinking phases: comprehension, comparison, analysis, and evaluation. Each of these critique phases involves examination of the steps of the quantitative research process and identification of the strength and weaknesses of this process (Burns & Grove, 2006). The study named,’ Use of central venous Catheter-Related Bloodstream Infection( CR-BSI) Prevention Practices by US Hospitals’ is a quantitative design (Krein, Hofer, Kowalski, & Olmsted, 2007). The purpose of the study was to determine the extent to which US acute care hospitals have adopted central venous CR-BSI prevention practices and to identify the factors that encouraged their adoption.

The need of this study was due to the rising healthcare infections that affect more than 2 million hospitalized patients annually and the cost of the US healthcare system more than 6 million in excess charges (Center for Disease Control and prevention, 2006). According to Center for disease control and prevention (CDC), CR-BSI affects more than 200,000 patients annually in US and increases morbidity, mortality, length of hospital stay, and healthcare cost. The purpose of this study is to determine the usage of recommended guideline in US hospitals in delivering care to prevent healthcare induced blood stream infection. The authors have comprehensible knowledge about the problem and purpose of the study. The study included the individual infection prevention practices recommended by the CDC guidelines and the protocols and guidelines advocated by organizations such as the institute of Healthcare improvements (IHI). Researchers evaluated the factors that would be associated with the adoption of infection prevention practices: such as centralized administration like Veterans Affairs (VA) healthcare system, a guideline recommendation for a specific procedures, and hospital characteristics, such as dedicated hospital epidemiologist. Researchers have focused on possibilities in various hospital settings, which can affect the prevention of CR-BSI.

This is the trial to reduce extraneous error in data collection, so that many systems have individualized protocols and guidelines. The authors compared the practices in different hospital systems to acquire the knowledge about the use of recommended practice in delivering the care at frontline nursing practices (Krein et al., 2007). Data collected between March 16th 2005 and August 1st 2005. Questionnaires were sent out to infection control coordinators at 719 hospitals across the United States. If hospital has more than one infection control coordinators, the supervisor was asked to complete the survey. Hospitals were selected from the American Hospital Association (AHA) database from the fiscal year of 2003 data and to identify the nonfederal, general medical and surgical hospitals with more than 50 beds and has an Intensive Care Unit. A random sample of 300 hospitals was selected from each stratum, of total sample 600 hospitals. All VA medical centers operating with acute care beds are also included in data collection (n=119). Supplementary data collected from AHA database, and VA Ann Arbor Healthcare System (Krein et al., 2007).

The random sample collection and large enough sample are the significant strengths of this study. Some bias can be involved in sample selection because data collected from AHA from the year 2003. Data has been retrieved from many databases. That can cause extraneous error in data collection. Data collection method was appropriate in acute care hospital setting from the infection control co coordinators. Availability of subject, facilities, and equipment were discussed in data collection section. Environmental error and documentation error can occur in this data collection due to the variety of hospital culture at the participating institutions even though the researchers have assessed it. These are the weakness of the study. So validity of study may be altered due to wide range of environment and hospital safety culture is involved in the data collection process that can cause extraneous errors.

Independent variables are indicated as regular use of specific practice for preventing CR-BSIs, hospital characteristics, and infection control program features. These variables derived from the survey questions about the CR-BSI infection prevention practices. Dependent variables were proper usage of sterile barrier precautions such as gown, mask, gloves, large patient drape, chlorhexadine, changing of central lines, and antimicrobial central venous catheters. Responders rated the frequency of usage at the Likert scale of 1-5 and 1 marked as regular use in practice. Confounding variables are included as hospital leadership number of ICU beds, nurse staffing guidelines, level of facility support for the evidenced based practices, location of the hospital and patient populations. Authors analyzed the data using weight of the sample by VA hospitals and non-VA hospitals and probability of selections in each category. They used descriptive model and bivariate analysis in VA system and non-VA systems to compare the data. Authors constructed weighted logistic regression models to examine which of primary independent variables were associated with the use of each practice of interest. Regression results are reported using odds ratio values and 95% of confidence interval (CI) ranges (Krein et al., 2007).

Overall results of response rate 80% of VA and 70% of non VA- hospitals. VA hospitals scored higher rate of using sterile barrier precautions (84%) and that of non VA-hospitals (71%) of using recommended practices. Logistic regression results reflect that VA hospitals use chlorhexidine 5 times and using composite approach twice as that of non VA hospitals (Weeks &Bagian, 2000). An association was found between higher use of CR-BSI prevention practices and a higher safety culture score. Chlorhexidine impregnated dressing is used in 25% hospitals although it is not recommended by any of the published guidelines and the popularity of this is growing (Krein et al., 2007). Findings also revealed that most hospitals adopt the practices that have been strongly recommended by published evidenced- based guidelines. The authors have analyzed the information and given recommendations for the practice that based on the evidence and the results of the study. Authors also included two other studies related to this topics: 1) Survey by Warren et all where 25 ICUs in 10 hospitals where studied that had specific policies stipulating the maximum use of sterile barrier precautions and chlorhexidine for skin preparation, only in 28% of the units and 8% of the hospitals followed the policy( Waren, Yoke, &Climo,2006).

Rubinson et all, an Intensivist has done a study shows that 17% of hospitals that utilized impregnated CVS catheter and that of 28% reported full use of maximum barrier precautions (Rubinson, WuAW, Haponik, & Diette, 2003) Authors concluded the study that although many US acute care hospitals are following guidelines and using specific recommended practices for preventing CR-BSIs, fewer than half of the non- VA hospitals are concurrently using 3 practices widely recommended to prevent CR-BSIs. To improve adoption of key CR-BSI prevention practices, hospitals can begin by fostering a culture of safety, encouraging ICP certification in infection control, and participating in infection control collaborative (Krein et al., 2007). Authors have explained about the limitations of study. These are such as: the measure of regular use of a practice is a global assessment and does not identify if the practice is adequately implemented. Response bias can exist that the respondents provide the information of what they perceive to be a preferred answer. Anonymity of the respondent was considered in order to minimize the biased response. Infection control professional may not be the most knowledgeable personnel in some practices of nursing. This author’s workplace had an opportunity to participate in this data collection process in prevention of central line blood stream infection (CL-BSI) prevention process in Adventist healthcare system.

That workplace has been free of CL-BSI in last one year. This data collection and monitoring inspired the frontline staff to strive for patient safety and safety culture of the hospital (Der.Y, personal communication at work place, October 21st, 2008). This study has been an instrumental to for the National Nosocomial infection Surveillance System to the 100,000 lives campaign of the IHI. This information also included in national patient safety goals of the institutions and accreditation organizations (Krein et al., 2007). This shows the implications of this study to the nursing practices in the hospitals as evidenced based practice. Overall this study has some implications for the current nursing practices to prevent central venous catheter related blood stream infections in acute care setting.

This evidenced based data and recommendations will allow the hospitals to implement and practice the use of central venous catheter related bloodstream infection prevention methods. The authors had a comprehensible knowledge about the problem and purpose. Authors analyzed the data statically. They also compare the systems and practices with openness and given recommendations. The study limitations and errors were mentioned. They have given the results and recommendations for the implementation to promote the national goals for the patient safety campaign.

References

Burns, N., & Groves, S. K. (2007). Understanding Nursing Research (4 ed). Philadelphia, PA: Philadelphia, PA: Elsevier Saunders Centers for Disease Control and Prevention (2006). Statistics and Surveillance. Retrieved July 23, 2008, from www.cdc.gov// Krein, S. L., Hofer, T. P., Kowalski, C. P., & Olmsted, R. N. (June 2007). Use of Central Venous Catheter-Related Bloodstream Infection prevention Practices By US Hospitals. Mayo Clinic Proceedings, 82(6) P. 672. Retrieved October 30th, 2008, from http://proquest.umi.com Pronovost, P., John Hopkins University Quality Research Group, Adventist Healthcare Systems, ICU data Analysis CL-BSI (1ST
Quarter, 2008). Rubinson, L., WuAW, Haponik, E.F., Diette, G.B., Internist adherence to guidelines for prevention of intravascular catheter infections, JAMA, 2003 290(2802) Warren, D.K., Yokoe, D.S., Climo, M.W., et all, Preventing Catheter Related Bloodstream Infections: Infection Control Hospital Epidemiology, Jan2006, 8(13). Weeks, W.B., Bagian.J.P. Developing a culture of Safety in Veterans Health Administration, Effective Clinical Practice, 2000. (3).