Critical Appraisal and Implementing Evidence in Practice

Abstract

Central Venous Catheter (CVC) is very important in managing Catheter-related bloodstream infection (CRBSI) which is a substantial basis of morbidity and mortality in the ICU settings. Evaluation of the impact of central venous catheters impregnated with silver sulphadiazine and chlorhexidine is a very important topic of study for resource implications, prolonged stay and associated costs at the Intensive Care Units go hand in hand (Osma et al. 2006, 159). The bloodstreams infections are a major source of complications to the patients and end up increasing the patient’s length of stay, health care costs and the mortality rate. Measures taken to reduce these infections include impregnation of central venous catheters (CVCs) with antibiotics and antiseptics. The study relies on the secondary information gathered from researches between 2001 and 2016. The studies focused on the adult medical-surgical patients in intensive care units in different hospital settings in different countries with their consent, or their legal guardians signed consent forms (Perin, et al, 2016, 24). To facilitate a good understanding of the practice,  the study in consideration will make use of qualitative research design in which an analysis of patients  whose cases have been handled making use of antibiotic-coated  CVC will be compared with medical results of patients were handled  with standard central line.  Following the positive impacts associated with Central venous Catheter the evidence-based practice should be implemented in health centers.

Background

Central Venous Catheter (CVC) is very important in managing Catheter-related bloodstream infection (CRBSI) which is a significant cause of morbidity and mortality in the ICU settings. This research topic is important because it is one of the medical conditions that contribute to the prolonged stay, resource implications, and associated costs. The efficacy of many other proposed interventions to reduce the burden of infection remains controversial. However, central venous Catheter can be used in several ways including to monitoring the infection and dealing with it especially due to the fact that use of antiseptic-impregnated central venous catheters does not affect the prevalence of either catheter-related bloodstream infection or catheter colonization in critically ill patients. The study is also important as it notes that routine preferential use sub-clavian vein insertion site and catheter change are associated with increased risk of mechanical complications outweighing the potential benefits. The patient is also at risk of bloodstream infections related to the use of the silver and antiseptic catheters in the questionable benefits in the ICU patient population which is usually unjustified in terms of cost and efficacy. These bloodstreams infections are a major source of complications to the patients and ends up increasing the patient’s length of stay, health care costs and the mortality rate (Wassil, et al. 2007 79). To reduce these infections measures taken includes impregnation of central venous catheters (CVCs) with antibiotics and antiseptics. Moreover, these antibiotics at times have resistance and cause side effects or allergies to the patient.

Method

The study relies on the secondary information gathered from researches between 2001 and 2016. The studies focused on the medical-surgical patients in intensive care units in different hospital settings in different countries with their consent, or their legal custodians signed approval forms. All the patients in the primary studies were adults, that is, over eighteen years. Patients and catheter characteristics are documented and peripheral blood cultures obtained during the removal of the catheters (Kallen et al. 2010, 336). When CVCs are inserted, such antiseptics as chlorhexidine which has greater ability in decreasing infection rates when likened to others are sued to prepare the site. In less than three years, exclusion duration was anticipated; pregnancy; allergy to chlorhexidine, silver or sulphonamides; dermatitis; signs of systemic inflammatory response syndrome and sepsis; or a burn over the attachment site (Osma et al. 2006, 160). After the insertion of the catheter patients were set to the antiseptic triple-lumen catheter which was impregnated with silver sulphadiazine and chlorhexidine. The computer-generated randomized list was used to perform randomization.

These studies were developed in line with the PICO frameworks from P which represents the patients who are in this case presented in different groups according to the different research. I represent the interventions which include impregnation of central venous catheters (CVCs) with chlorhexidine and silver sulphadiazine in the prevalence of catheter-related and colonized bloodstream infections in critically ill patients. C-represents control measures taken which include the central venous catheters (CVCs) impregnated with silver sulphadiazine and chlorhexidine (Osma et al., 2006, 159). Sterile techniques and maximal barrier precautions are crucial in reducing the rate of catheter-related BSI. Conservation of the catheter is crucial. The O represents the outcomes which indicate the catheters whose external surfaces are impregnated with chlorhexidine and silver sulphadiazine are the subjects of meta-analysis which established a substantial reduction in catheter-related blood-stream infections and also catheters colonization was also reported in the results of the studies that used antiseptic catheters (Osma et al. 2006, 163).

The methods used observed that proper hand hygiene afore the catheter manipulation is essential to avoid catheter hub contamination prevention. Other than the traditional gauze and tape dressing, transparent is equally efficacious. The transparent dressing allows for proper hygiene care of the patient and easier visual inspections of the site. This dressing is efficient for it requires less frequent dressing changes compared to gaze and tape dressing and also for the prevention of saturation of site (Veenstra, et al. 1999, 557). Critically ill patients are at a higher risk of catheters related infections because of the frequent monitoring and also receive multiple medications, and hence more manipulation of the catheters is necessary. Such methods are necessary for the nursing student for this kind of information is important as proper catheter care and minimized manipulations of the catheters.

The studies were conducted in accordance with the protocol including establishing the research questions that is the use of the PICO strategy. Other protocol observed includes collecting data, critically assessing studies, identifying and selecting studies, interpreting results, and analyzing and presenting data (Wassil, et al. 2007, 80). The PICO policy ensued in the following question: ‘What are the catheter-related bloodstream infections related prevention measures implemented among the adults hospitalized in the intensive care unit?’ The studies included the answered research questions, related to the topic, addressing interventions to the maintenance and upkeep of catheters. Also, the studies included the adult patients steered in the ICUs, short-term CVCs, and which offered titles and extracts that focused on the subject (Veenstra,et al. 1999, 558).

Other studies chose at random patients to receive either a standard triple-lumen catheter (69) or an antiseptic-impregnated triple-lumen catheter (64). The mean of the standard catheters and duration for the antiseptic ranged around 11.7 days. The time of removal colonized fourteen of the days of the antiseptic catheters and 14 of the standard catheters. Antiseptic catheters were associated with catheter-related bloodstreams infection. The gap between the antiseptic catheter group and standard catheter group does vary although antiseptic catheter group took fewer days compared to the standard catheter group (Kallen, et al. 2010, 338.). This study showed the variance in the catheter groups does not affect one another. That is, use of antiseptic-impregnated central venous catheters has no significant consequence on the occurrence of either catheter-related bloodstream infection or catheter colonization in very sick patients.

The in-line filters are not proved by any means to prevent or decrease the catheter-related BSI. However, the inline filters remove particular matters that may contaminate the infusate, diminish the risk of contamination from adulterated infusate, sifter out endotoxin formed by gram-negative organisms although catheters related BSI as a result of infusate is rare (Perin,et al. 2016, 24).

Exclusive criteria’s in the studies addressed pediatric or neonatal population, hemodialysis, peripherally, or peripheral and arterial catheters and inserted a central catheter (PICC). The study fails to address the preventive methods to avoid central line-associated bloodstream infections. A total of seven studies that meet the inclusion criteria are also available in full texts and are initially selected and used in this study (These studies were developed in line with the PICO frameworks from P which represents the patients who are in this case presented in different groups according to the different research. I represent the interventions which include impregnation of central venous catheters (CVCs) with chlorhexidine and silver sulphadiazine in the occurrence of catheter-related and colonized bloodstream infections in censoriously ill patients. C-represents control measures taken which include the central venous catheters (CVCs) impregnated with silver sulphadiazine and chlorhexidine (Osma et al., 2006, 159). Sterile techniques and maximal barrier precautions are important in reducing the rate of catheter-related BSI. Preservation of the catheter is crucial. The O represents the outcomes which indicate the catheters whose external surfaces are impregnated with chlorhexidine and silver sulphadiazine are the subjects of meta-analysis which validated a substantial decline in catheter-related blood-stream infections and also catheters establishment was also reported in the results of the researches that used antiseptic catheters (Osma et al. 2006, 162). The studies used in this research are also blended and scrutinized and prearranged in a scrutiny tool that includes references, methods, care, level of evidence and result.

Critical appraisal

As it was noted in the latter section of the essay the objective of the research in consideration of is reviewing the efficiency of chlorhexidine impregnated or antibiotic-coated CVC in comparison with the use of standard central line and side effects of the evidence-based practice.  To facilitate a good understanding of the method,  the study in consideration will make use of qualitative research design in which an analysis of patients  whose cases have been handled making use of antibiotic-coated  CVC will be compared with medical results of patients was handled with the standard central line.  The nature of the study in question indicates that the inquiry will involve analyzing information conveyed through language and behavior in a hospital setting.  Qualitative research methodology best fits such studies since it involves capturing expressive information that may not be essay to capture when making use of quantitative research method (Holloway 2015, p.34).  Some of the information that the research design will gather regarding the topic in consideration are for instance beliefs, values, and believes that people hold regarding the issue of making use of Central Venous Catheter

Together with covering a wider scope of the investigation, appropriateness of qualitative research design is also facilitated by the many advantages that are associated with the research methodology. A notable position that has made adaption qualitative research design a useful tool in conducting the research in question is that issues and subjects are coved and evaluated in depth and detail (Holloway 2005, p.47).  Additionally, the research design gathers data from few individuals thus making it is possible to make a quicker analysis of the results obtained. Despite the noted strength of qualitative research methodology, it is subjected to a significant disadvantage in that it is subjected to the potential harm of bias in the process of gathering relevant information in regard to the subject in question.

In a clinical research making use of qualitative research methodology, instances of bias are brought about by a wide range of reasons. The first major reason that contributes to bias is instances of respondents saying yes to everything about whatever the moderator presents. The resultant of such the stipulated form of bias is that the researcher will end up collecting the wrong type of data.  In addition to the discussed type of bias, habituation is also a type of bias that is experienced in the process of gathering data making use of qualitative research methodology.  Cases of habituation are evidenced when the respondents provide the same answers to questions that are formulated in a similar way (Lewis, Mcgrath, & Seidel, 2011, p.299). In most cases, such form of bias is realized because of biological response in which paying attention takes a lot of energy.

Aiming at mitigating the biases associated with qualitative research design, the researcher can opine going for a quantitative research design that provides a solution to the bias problems associated with qualitative research design.  Even though quantitative research methodology can provide means of mitigating instances of bias, the method is subjected to issues in the process of data collection that compensates the effectiveness of the research in question. For instance, making use of quantitative research study, it is not possible to collect logical data since quantitative research design applies best in when collecting numerical data.  The study in question in consideration aims at finding out the efficiency using Central venous Catheter thus embarking of quantitative methodology implies that the research will not provide detailed information on the topic in consideration.  In addition to miss presentation of data, research making use quantitative methodology are subjected to a challenge of data analysis since they require high-level professionalism

After making use of the discussed in the above paragraphs research methodologies, it was evidenced that Central venous Catheter bears better results when used to provide care to patients with severe diseases cured with surgical procedures, intensive care, and oncological units.  As compared with making use of standard central line, Central Venous Catheter ensures quick recovery of the patient. It was however noted that Central venous Catheter increases the risk of deep venous thrombosis but decreases the risk of Cather occlusion.  The most disturbing issue associated with the adaption of Central Venous Catheter is that it is costly and requires specially trained medical practitioners to perform the task.  If not handled in the right way, the research in consideration argued that Central venous Catheter leads to other complications such as infections and dislodgment of tissues.  Furthermore, Central Venous Catheter, if not handled properly, results to increase morbidity and suffering of the patient which may result to change of body image of the patient in consideration.

Implementation plan

Even though making use of Central Venous Catheter bears some negative implications to the patients, the positive effects associated with embracing   Central venous Catheter outweighs the negative impacts it carries.  Following the positive impacts associated with Central Venous Catheter, the evidence-based practice should be implemented in health centers.  To be in a position of implementing changes in a clinical health center that were initially using the standard line to one that will be using  Central Venous Catheter,  it serves great significant considering arguments presented by  Lewin’s Force field analysis (Lewis, 2007,  p.282). According to stipulations put forward by Lewin, the process of implementing change is subjected to many challenges with the most obvious issue being the force of equilibrium.

The philosopher continued to argue that whenever driving forces are stronger than restraining troops in a change implementation is possible to inflict the so determined changes in a system. Considering the stipulations put forwards by Lewin, some of the significant forces that will facilitate changes in handling the patients with the use of Central Venous Catheter are the advantages that are associated with the technology as compared to making use of standard central line.   Even though Central Venous Catheter is associated with the mentioned advantages, its implementation might face some barriers such as employees’ resistance to change, a high cost of application and requirement of high technological devices.   It should, however, be noted with proper procedure implementation of the Central venous Catheter will present no challenges to the health center implementing it.

Conclusion

To proper implementation of the evidence-based practice noted in the essay, various steps should adhere. The first step is defining the changes expected after the implementation. Secondary, evaluation of the driving and restraining forces on the implementation process should be the second step governing the change implementation process, Thirdly, a review of identified strengths should be conducted. The method of defining the review is vital since it determines forces that have some flexibility for change and those which cannot be influenced.

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