Evidence based practice (EBP) helps integrate clinical care with the aim of improving clients (patients) outcome (Parienti et al., 2012). As nurses continue to master the practice, they are faced with the problem of searching for the best evidence to support both assessments and interventions, refine strategies and develop new policies as well. Although determining substantial evidence from simpler one is a complicated process, a qualitative research method helps provide valuable knowledge for the nurses in their practice. Marinho and da Cruz (2013) assert that qualitative research provides its results through participant’s words that can be easily applied to the nursing care practice. However, nurses are attracted to this research since its methods plus findings conform to the nursing practice where understanding and knowing the patient wholly matters the most. Ultimately, the primary role of EBP is to provide the patient with clinical services at a personal level. Apart from being continuous, EBP also provides dynamic integration of clinical expertise as well as external evidence in daily practices (O’grady et al., 2011).
This essay discusses the question on whether the use of Chlorhexidine dressing decreases central venous catheter infection rates (CVCIs) compared to standardized dressing in adults hospitalized in high complex settings. Its rationale is that although a majority of vascular catheter –related infections occurs in people with highly complex settings, Chlorhexidine dressing can help reduce the infection rates.
Master of Science nursing abbreviated as MSN is a program that deals with the preparation of graduates for advanced nursing practice as well as doctoral study, while family nurse practitioner (FNP) is a speciality track that helps learners expand their nursing practice (Parienti et al., 2012). The track prepares nursing students to manage healthcare needs of the patients, focus on promotion of health and prevention of diseases, diagnosis and management of chronic and acute illness. In the nursing school, Parienti et al., (2012) hold that the practitioners do acquire both skills and knowledge needed to perform nursing assessments as well as apply sequence of steps when conducting procedures. The MSN, FNP speciality track will therefore provide an FNP with the necessary skills to understand the use of chlorhexidine (an antiseptic agent for skin disinfection) and know whether it has any effect on the central venous catherization (CVC) such as the impact on infections.
Less than usual, results such as skin breakdown and infections would occur when a nurse skips steps in their procedures or have not fully mastered the skills (Loveday et al., 2016). Most of the times, they draw knowledge from past educational instructions when making decisions regarding performance in their practices. According to Loveday et al., (2016), the track also help nurses to synthesize knowledge from humanities, sciences as well as nursing theories to uphold advanced nursing practice and develop practical approaches of EBP including nursing research. Most importantly, the FNP track would help a learner understand that vascular and CVC cause severe morbidities and mortality in elderly patients. Also, they would be able to examine the chlorhexidine (antiseptic agent) dressing effects on the risks of epidural as well as catheter bacterial infections and colonization (Chan et al., 2012).
Methods
The essay describes the steps involved in implementing an EBP model for decision making at service levels using a case report. The essay also demonstrates findings of systematic reviews evaluating the effects of continued use of the Chlorhexidine in lowering CVCIs. The dressings are fit at the entry sites of the central venous access device (CVAD) and covered to protect them.
The EBP model helps in guiding the implementation of research into nursing practice using necessary procedures to improve the client’s outcome (Garland et al., 2001). The model is used to guide the current case report.
CVCIs are linked with mortality rates of over 12%. As Kim et al., (2011) asserts, the accepted methods of reducing catheter related infections include use of appropriate solutions for the skin antisepsis and access of line, immediate removal of unnecessary catheters and preferential subclavian catherization. Although dressings become detached in patients in the intensive care unit, decreasing skin colonization by bacteria at the site of insertion by using antiseptic dressings can reduce the risks of CVCI (Kim et al., 2011). It has been shown that the use of chlorhexidine can decrease a majority of catheter infections including catheter related blood infections (CRBI).
A PICO tool was used to ask the following question: “Does the use of antiseptic chlorhexidine dressing decrease central venous catherization infection rates when compared to other standardized dressing in adults hospitalized in high complex settings?”
|
Element |
|
|
Problem/population |
In adults hospitalized in high complex setting |
|
Intervention |
Does antiseptic chlorhexidine |
|
Comparison |
Compared with standardized dressing |
|
Outcome |
Effective in decreasing central venous catherization infection rates |
After identifying the clinical question, a literature search was conducted locating a systematic review. Use of systematic reviews has been recognized in healthcare settings for informing clinical questions. A metal analysis conducted showed that use of chlorhexidine dressings favoured reduction of CVI rates in adults than standardized dressings. The purpose of reviewing was to compare the number of CVIs occurring in adults where chlorhexidine was used against the number of infections in people who used non-chlorhexidine dressing in determining the effectiveness of chlorhexidine to reduce the catheter colonization and infection rates (Chan et al., 2012).
A standard Cochrane collaboration methodology was used and search done for relevant articles using different databases such as Medline, CINAHL and EMBASE. Each paper was reviewed independently and control trials which the impact of chlorhexidine dressings was compared to a group that received standardized dressings. Meta analyses were conducted using outcome of the studies. Fortunately, the results favoured use of chlorhexidine dressing on the entry sites of catheter to reduce CVI rates.
The forest plots evaluated use non-chlorhexidine against use of dressings and compared/contrasted prevalence’s of CRBI and catheter colonization between the groups (O’grady et al., 2011). Irrespective of the methodological disparities between the studies, heterogeneity of the Meta analysis using CRBI as the main result was zero. Since hetegonitiy was far much high for catheter colonization, it would be considered less significant. According to Parienti et al., (20012), this insignificance showed that pooling of data in the trials was necessary. However, the number needed for treating analysis to reduce CRBI was 62. Hence, these dressings can be used to prevent catheter colonization’s in every ten persons.
Nurse unit manager and nurse researcher discussed outcome of the review as well as subsequent effects for clinical practice (Marinho and da Cruz, analysis in this 2013). The review favoured the use of chlorhexidine on reducing CVCI. Apart from the consideration of the evidence, cost analysis was conducted where each dressing costs $6.00 and needed to be changed twenty-four hours following catheter insertion. As per the local database, the average length of time that the central venous access device was in situ in adults hospitalized in ICU was 29 days and would requires six dressing during the period, hence cost of preventing one episode of CRBI was very high. To summarize, this review concluded that chlorhexidine dressing provides simple yet cost effective method of reducing the incidences of CRBI occurring in adult patients.
A systematic review of this report showed chlorhexidine dressings as cost effective yet simple clinical intervention of reducing CVCIs incidences in adult patients. Also, the case report showed that the problems encountered by the Clinicals were in making decisions based evidence. Despite the fact that there are frameworks available to facilitate EBP, the case report showed a possible operationalization of a collaborative model. However, the model was a key to the success of clinical cases among the nurse administrators, clinical nurse plus the researchers. As Kim et al., (2011) asserts it is also important to acknowledge that there were randomized control trials available for analysis.
In instances where enough evidence cannot be found, it is wise to wait for evidence from primary research before the practice change. However, the scope of the essay is confined to a report of EBP process but failed to find the practice change effects regarding the clinical outcome. Hence, this report presents the steps for EBP and provides rational and analysis of cost-effectiveness estimation for proofing the practice change. Also, it’s noted that in an ideal scenario, the reviewing conducted in the EBP needs to be peer reviewed.
Conclusion
A research utilization collaborative method in healthcare is appropriate to inform the dressings practice as well as ensure its effectiveness is delivered with the aim of improving healthcare’s outcome. A friendly environment and infrastructure for enquiries in clinical as well as research are known to enable implementation of the EBP. Therefore, it has been evident from the analysis that the use of antiseptic chlorhexidine dressing reduces central venous catherization infection rates when compared to standardized dressings in adults hospitalized in high complex settings.
References
Chan, R., Northfield, S., Alexander, A., & Rickard, C. (2012). Using the collaborative evidence based practice model: a systematic review and uptake of chlorhexidine-impregnated sponge dressings on central venous access devices in a tertiary cancer centre. Australian Journal of Cancer Nursing, 13(2), 10-15.
Frasca, D., Dahyot-Fizelier, C., & Mimoz, O. (2010). Prevention of central venous catheter-related infection in the intensive care unit. Critical care, 14(2), 212.
Garland, J. S., Alex, C. P., Mueller, C. D., Otten, D., Shivpuri, C., Harris, M. C., … & Goldmann, D. A. (2001). A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics, 107(6), 1431-1436.
Kim, J. S., Holtom, P., & Vigen, C. (2011). Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: epidemiologic and economic consequences. American journal of infection control, 39(8), 640-646.
Loveday, H. P., Wilson, J. A., Prieto, J., & Wilcox, M. H. (2016). epic3: revised recommendation for intravenous catheter and catheter site care. Journal of Hospital Infection, 92(4), 346-348.
Marinho, J. S., & da Cruz, I. C. (2013). Reduction of infection associated with central venous catheterization by antiseptics-Sistematic Literature Review. Journal of Specialized Nursing Care, 6(1).
O’grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., … & Raad, I. I. (2011). Guidelines for the prevention of intravascular catheter-related infections. Clinical infectious diseases, 52(9), e162-e193.
Parienti, J. J., du Cheyron, D., Timsit, J. F., Traoré, O., Kalfon, P., Mimoz, O., & Mermel, L. A. (2012). Meta-analysis of subclavian insertion and nontunneled central venous catheter-associated infection risk reduction in critically ill adults. Critical care medicine, 40(5), 1627-1634.
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