PICO framework

Within Clinical settings the prevalence of nosocomial Methicillin resistant Staphylococcus aureus (MRSA) infections is rising which is placing more patients at risk of acquiring an infection and placing more strain on the health care system, as patients receiving these infections are occupying hospital beds for extended periods of time (Chaberny et al 2008, p 526). With this knowledge, the author has identified that there is a lacking of screening measures that, if implemented, may help to reduce patients being exposed to nosocomial infections whilst in the clinical setting. Therefore, the question the author has developed asks “Does MRSA screening on admission, reduce the risk of other patients in acquiring a nosocomial infection within surgical wards”.

Whilst utilising the PICO framework (Glasziou, Del Mar & Salisbury 2007), the author has identified the following criteria, which assisted them with searching for relevant articles in assistance of answering the authors question. The PICO framework (Glasziou, Del Mar & Salisbury 2007) identified;

P – Patients at high risk of infections.
I – Admission screening for MRSA
C – No admission screening.
O – Decrease MRSA infection rates.

The author identified and chose three articles, of which they will provide a short description. Following this, an in depth critique attempting to identify if the material chosen relevant to the topic and aids in answering the authors question will be provided.

To identify and locate these articles, the author used the University of Wollongong database access. Starting at the University of Wollongong home page the author continued to the ‘Library’ Section. By selecting the ‘Databases, Journals’ tab this allowed the author to access all of the databases available for current university students. To narrow the authors search down, the author entered the databases available and appropriate for Health and Behavioural sciences. The author then proceeded to select the CINAHL (Cumulative Index to Nursing and Allied Health Literature) database, as the author has used this before and found it helpful in identifying relevant and current research.

The author then performed a searched using the key words ‘MRSA’ and ‘admission’, which were found to be too broad of a search parameter. The author narrowed their results further by using the key words ‘MRSA’, ‘admission’ and now included the term ‘screening program’. By selecting to see full text results along with those which had been peer reviewed and had references available, the author was then able to narrow their results. To narrow the search results further, the author stipulated that only articles published within the last 10 years were needed to be displayed.

The ‘Effectiveness of a hospital-wide selective screening programme for methicillin-resistant Staphylococcus aureus (MRSA) carriers at hospital admission to prevent hospital-acquired MRSA infections’ article is a quantitative research paper, which researches if admission screening in a German hospital will reduce the amount of MRSA outbreaks. The Study describes the effects of hospital wide screening for those within a defined risk group.

The study conducted within a 700 bed hospital during a period of nineteen months. The frequencies of hospital acquired MRSA infections were compared with and without the screening. During the control period, 36118 inpatients were observed including 119 MRSA patients, whilst 36932 patients were observed during the screening period of the study which included 205 MRSA patients. The results showed that 3.3/1000 admissions during the control period were positive for MRSA, compared with 5.5/1000 admissions during the screening phase. This result shows that when there are screening measures in place for MRSA, more patients are identified as having the virus, therefore, they can receive treatment which will place health care workers and other patients at less risk of acquiring an infection as those carrying the infection have been identified. Further results showed that within the control phase of the 119 identified with having MRSA, 51 patients met the studies criteria for high-risk patients who have an increased chance at infecting others. Whilst during the screening process 114 of the 205 were identified as being high-risk. This again demonstrates that the need for screening programs as they allow for identification of MRSA positive patients which may, if not identified place other patients and health care works at risk of cross infection.

The second article selected, ‘A point prevalence study for MRSA in a German university hospital to identify patients at risk and to evaluate an established admission screen procedure’, was conducted due to the increasing rates of MRSA in Germany. It is a cross-sectional study conducted to determine the incidence of MRSA and Panton-Valentine leukcidin (PVL) among a range of inpatients. The study further focused on identifying patients at risk for MRSA colonization within the clinical setting. The study was conducted within a 1330 bed university hospital located within North West Germany. It was conducted over twenty two days in 2005. The results of the study found that, of 509 inpatients, 27 were found to be MRSA positive carriers. Nosocomial acquisition was identified in 3 patients, and 4 patients were found to have MRSA identified on the wards without routine screening.

The third article selected, ‘Reduction in the rate of methicillin-resistant Staphylococcus aureus acquisition in surgical wards by rapid screening for colonization: a prospective, cross-over study’, aims at early identification of colonized patients using rapid methods alone reduces transmission. Based in a large 1200 bed teaching hospital, between January 2005 and April 2007, 13 952 patients were screened on admission within the nasal carriage and every forth day thereafter. Swabs were inoculated directly onto chromogenic culture media (this is the gold standard test for MRSA detection and identification (Cherkaoui et al 2007, p 500)), rapid results were reported immediately on completion of the test whilst awaiting the culture result.

Culture plates were then examined after eighteen hours of incubation (standard procedure (Merck manual 2011)). Results showed that the introduction of MRSA screening using rapid testing had significantly reduced MRSA transmission on wards that had limited isolation rooms.

In order for health care workers to adopt their findings from an article, a critical review of the article is necessary (Hammersley 2008, p 748). Health care workers need to assess the reliability of the article through asking and answering questions which will identify the overall strengths and weaknesses of the studied research (Morris 2010, p 124; Glasziou, Del Mar & Salisbury 2007). In order for this to happen questions will be adapted from Glasziou, Del Mar & Salisbury (2007) and utilized to deduce the strengths and weaknesses from the three articles researched.

The article by Wernitz et al (2005), aims at identifying the effectiveness of hospital wide screening on admission in an attempt to curb MRSA infections. The aim of the study is clear and appropriate and provide clear introduction to the topic under investigation (Glasziou, Del Mar & Salisbury 2007). The importance of the study is as stated; there is an increase in MRSA infections and no treatment plan available (Wernitz et al 2005, p 458).

The study states a valid hypothesis, which is to be study if screening on admission, along with preventive contact isolation for those in the high risk categories, will reduce the spread of MRSA. The article did not state what form of study that the authors used, yet it stated that the study was conducted over two periods, and control a screening period over the span of nineteen months. The sample size was appropriate, as 36118 patients were observed, the location of a large teaching hospital within a developed country, and the reliability of the study is justified when the characteristics of the study match the location (Morris 2010, p 124; Glasziou, Del Mar & Salisbury 2007).

As it may not be appropriate to study MRSA rates at clinical settings where there has been no identified increase (Schulz, Nonnenmacher & Mutters 2009, p 1291), the authors allowed and attempted to reduce random error by screening every patient that was admitted to the hospital. However, the authors illustrated that some patients declined to participate and that they may have altered the outcome.

Finally, Glasziou, Del Mar & Salisbury (2007) state, that to test the reliability of a study, the findings must be relevant and have the ability to be adopted into practice. The study by Wernitz et al (2005) depicts an increase in infection rates over time which suggests that current practice is not combating the problem. Early identification allows for those within the high-risk category to be identified and isolated so that other patients are not exposed to the infection (Wernitz et al 2005, p 464).

The article by Chaberny et al (2008), aims to study MRSA to identify patients at risk, and to evaluate an established admission screening procedure. The aim of this study is clear, as depicted in the title and throughout the introduction. The article gives clear background and importance of the study, again due to increasing MRSA infection rates (Chaberny et al 2008, p 527).

The study does not give a clear hypothesis, however it identifies a primary and secondary objective to determine the prevalence of MRSA and compliance of testing regimes. This can be seen as a weakness according to Morris (2010, p 124) and Glasziou, Del Mar & Salisbury (2007), a hypothesis should be found towards the end of the introduction to the article which allows the readers to have an understanding and the information that will proceed (Glasziou, Del Mar & Salisbury 2007).

A cross-sectional study was conducted which allows for a comparison between two groups of people at one time (Harris, Nagy & Vardaxis 2010, 461). That is one group being screened for MRSA, and the other compliance with admission screening. The sample size and collection techniques are appropriate and stated within the study, as a sample was taken from differing wards of the hospital (Chaberny et al 2008, p 526). A limitation noted by the authors that only one hospital was used within the study, and the study was conducted over a brief period of twenty two days. To make the results more relevant, Morris (2010, p 124; Glasziou, Del Mar & Salisbury 2007) suggests that a large and appropriate sample need to be taken as the results may be appropriate for that clinical setting but not another. This does not depict the overall picture of the study.

Finally, are the results and overall findings relevant to the authors’ question?. Of the 509 patients 27 were MRSA positive, yet 37% of all MRSA patients were not found upon screening. Nosocomial acquisition was found in three patients, and four patients were identified with having MRSA on the wards without prior screening (Chaberny et al 2008, p 526). Therefore, it can be seen that nosocomial infections rates are low, and are not always avoidable as pre MRSA screening procedures can fail due to other precipitating factors.

The article by Hardy et al (2010) compares two different screening techniques that can be used on admission to identify MRSA within the clinical setting. The aim of this study is clearly identified within the abstract stating that the wished to establish whether or not early identification of colonized patients through rapid testing alone reduces transmission (Hardy et al 2010, p 333).

Again, the importance of this study is to identify if early identification of high-risk patients will reduce the amount of cross infection within the hospital (Hardy et al 2010, p 333). The article clearly states the hypothesis within the introduction which corresponds with the title and main findings of the article. The study type conducted is a prospective controlled cross-over study, with different means of MRSA detection within each period (Hardy et al 2010).

Swabs were taken from each participant from the nasal carriage the difference in techniques was with the rapid testing as the samples were inoculated, but results were reported before the culture result, which can take up to eighteen hours (Merick manual 2011).

Again, the results are limited by the fact that the study was conducted within one hospital, yet a large and diverse sample size was used (Hardy et al 2010, p 335). Another limitation which was identified by the author is that each patient was expected to be tested every four days, yet due to circumstances there was a large amount of patient transfer between wards and other clinical settings. This suggests to the author that all participants may not have been able to be screened within the allocated time frame. Results showed that rapid testing was shown to reduce the amount of MRSA acquisition with patients being 1.49 times more likely to develop nosocomial infection within wards that used the culture method (Hardy et al 2010, p 336). Chaberny et al (2008, p 528) state that there can also be associated factors within other areas which may contribute to the increase rates of MRSA acquisition.

From the research conducted by the author, it is evident that early identification of patients with a history of MRSA, or patients who fit into the high risk category, and therefore proceeding within proper infection control techniques will, in turn, reduce the amount of MRSA infections acquired within the clinical setting. Through the articles the author has identified the strengths and weakness that exist and how these have influenced the results. A major limitation for each study is that there was only one clinical setting that was used for the study. If multiple settings were used not just different wards, there may have been a broader range of results available. This then improves the validity and relevance of academic research which can then be initiated into policymaking and practice can change accordingly (Hammersley 2008, 759).

In conclusion, in association to the research the author conducted, it is illustrated that there is not a large amount of patients that are acquiring nosocomial infections within the hospital if there are admission screenings policies in place. This thereby reduces the risk of others, primarily patients and health care workers, from adopting an infection. It is further seen from the authors research that the use of MRSA screening may not in turn reduce the rate of infection, yet it identifies more people rapidly with the infection and thereby infection control polices set by the hospital are then able to be enacted before the infection has a chance to harbour in another reservoir.

Finally, with regards to answering the authors question “Does MRSA screening on admission, reduce the risk of other patients in acquiring a nosocomial infection within surgical wards”, it is concluded that rapid pre admission
screening on all patients will thereby identify a larger population of people with the infection, which therefore can be treated according, this thereby reduces the chance that other patients will be exposed to MRSA.

Reference list

Chaberny, I F, Bindseil, A, Sohr, D & Gastmeier, P 2008, ‘A Point-prevalence Study for MRSA in a German University Hospital to Identify Patients at Risk and to Evaluate an Established Admission Screening Procedure’, Infection, vol. 36, no. 6, pp. 526-532.

Cherkaoui, A, Renzi, G, Francois, P & Schrenzel, J 2007, ‘Comparison of four chromogenic media for culture-based screening of meticillin-resistant Staphylococcus aureus’, Journal of Medical Microbiology, vol. 56, no. 4, pp. 500-503.

Glasziou, P, Del Mar, C & Salisbury, J 2007, Evidence-based practice workbook, 2nd edn, Blackwell Publishing/BMJ Books, Massachusetts.

Hammersley, M 2008, ‘Troubling Criteria: A Critical Commentary on Furlong and Oancea’s Framework for Assessing Educational Research’, British Educational Research Journal, vol. 34, no. 6, pp. 747-762.

Hardy, K J, Szczepura, A, Davies, R, Bradbury, A, Stallard, N, Gossain, S, Walley, P & Hawkey, P M 2007, ‘A study of the efficacy and cost-effectiveness of MRSA screening and monitoring on surgical wards using a new, rapid molecular test (EMMS)’, BMC health services research, vol. 7, no. 1, pp. 160-168.

Hardy, K, Hawkey, P M, Price, C, Szczepura, A, Gossain, S, Davies, R, Stallard, N, Shabir, S, McMurray, C & Bradbury, A 2010, ‘Reduction in the rate of methicillin-resistant Staphylococcus aureus acquisition in surgical wards by rapid screening for colonization: a prospective, cross-over study’, Clinical Microbiology & Infection, vol. 16, no. 4, pp. 333-339.

Harris, P, Nagy, S, Vardaxis, N 2010, Mosbys Dictionary of Medicine, Nursing & Health Professions 2nd Australian and New Zealand Edition, Elsevier, Australia. Merck manual 2011, Normal laboratory values, viewed 5th May 2013, www.merckmanuals.com/media/…/pdf/Appendix_II-Table-1.pdf.

Morris, N 2010, ‘How to … Carry out a literature search’, Education for primary care : an official publication of the Association of Course Organisers, National Association of GP Tutors, World Organisation of Family Doctors, vol. 21, no. 2, pp. 124-125.

Schulz, M, Nonnenmacher, C & Mutters, R 2009, ‘Cost-effectiveness of rapid MRSA screening in surgical patients’, European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology, vol. 28, no. 11, pp. 1291.

Wernitz, M H, Swidsinski, S, Weist, K, Sohr, D, Witte, W, Franke, K, Roloff, D, Rüden, H & Veit, S K. 2005, ‘Effectiveness of a hospital‐wide selective screening programme for methicillin‐resistant Staphylococcus aureus (MRSA) carriers at hospital admission to prevent hospital‐acquired MRSA infections’, Clinical Microbiology and Infection, vol. 11, no. 6, pp. 457-465.