Health Medical
NRS 433V GCU Medical and Nursing Quantitative Research Essay

NRS 433V

Grand Canyon University

NRS

Question Description

Help me study for my Nursing class. I’m stuck and don’t understand.

Write a critical appraisal that demonstrates comprehension of two quantitative research studies. Use the "Research Critique Guidelines – Part II" document to organize your essay. Successful completion of this assignment requires that you provide a rationale, include examples, and reference content from the study in your responses.

Use the practice problem and two quantitative, peer-reviewed research articles you identified in the Topic 1 assignment to complete this assignment.

In a 1,000–1,250 word essay, summarize two quantitative studies, explain the ways in which the findings might be used in nursing practice, and address ethical considerations associated with the conduct of the study.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

PICOT question: In patients with central lines does the use of CHG wipes [daily] vs. standard baths decrease central line associated blood stream infections (CLABSI's) over 3 month.

P: Infection in patients with central lines.

I: Use of CHG wipes in patients with central lines.

C: No use of CHG wipes in patients with central lines.

O: Decreased infections rates

T: 3 month

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CLINICAL RESEARCH STUDY Chlorhexidine Bathing to Reduce Central Venous Catheterassociated Bloodstream Infection: Impact and Sustainability Marisa A. Montecalvo, MD,a,b Donna McKenna, MS,a,b Robert Yarrish, MD,c Lynda Mack, MSN,a George Maguire, MD,d Janet Haas, DNSc,a,b Lawrence DeLorenzo, MD,d Norine Dellarocco, MSN,e Barbara Savatteri, RN,f Addie Rosenthal, MS,g Anita Watson, RN,h Debra Spicehandler, MD,g Qiuhu Shi, PhD,i Paul Visintainer, PhD,j Gary P. Wormser, MD,b a Infection Prevention and Control Department, Westchester Medical Center, Valhalla, New York; bDivision of Infectious Diseases, Department of Medicine, New York Medical College, Valhalla, New York; cDepartment of Medicine, Sound Shore Medical Center, New Rochelle, New York; d Pulmonary and Critical Care Medicine, Department of Medicine, New York Medical College, Valhalla, New York; eInfection Control, Sound Shore Medical Center, New Rochelle, New York; fHudson Valley Hospital Center, Cortlandt Manor, New York; gMount Vernon Hospital, Mt Vernon, New York; hPhelps Memorial Hospital Center, Sleepy Hollow, New York; iNew York Medical College School of Health Sciences and Practice, Valhalla, New York; jBaystate Medical Center, Springfield, Mass. ABSTRACT BACKGROUND: Chlorhexidine bathing has been associated with reductions in healthcare-associated bloodstream infection. To determine the impact and sustainability of the effect of chlorhexidine bathing on central venous catheter-associated bloodstream infection, we performed a prospective, 3-phase, multiple-hospital study. METHODS: In the medical intensive care unit and the respiratory care unit of a tertiary care hospital and the medical-surgical intensive care units of 4 community hospitals, rates of central venous catheter-associated bloodstream infection were collected prospectively for each period. Pre-intervention (phase 1) patients were bathed with soap and water or nonmedicated bathing cloths; active intervention (phase 2) patients were bathed with 2% chlorhexidine gluconate cloths with the number of baths administered and skin tolerability assessed; post-intervention (phase 3) chlorhexidine bathing was continued but without oversight by research personnel. Central venous catheterassociated bloodstream infection rates were compared over study periods using Poisson regression. RESULTS: Compared with pre-intervention, during active intervention there were significantly fewer central venous catheter-associated bloodstream infections (6.4/1000 central venous catheter days vs 2.6/1000 central venous catheter days, relative risk, 0.42; 95% confidence interval, 0.25-0.68; P ⬍ .001), and this reduction was sustained during post-intervention (2.9/1000 central venous catheter days; relative risk, 0.46; 95% confidence interval, 0.30-0.70; P ⬍ .001). During the active intervention period, compliance with chlorhexidine bathing was 82%. Few adverse events were observed. CONCLUSION: In this multiple-hospital study, chlorhexidine bathing was associated with significant reductions in central venous catheter-associated bloodstream infection, and these reductions were sustained post-intervention when chlorhexidine bathing was unmonitored. Chlorhexidine bathing was well tolerated and is a useful adjunct to reduce central venous catheter-associated bloodstream infection. © 2012 Published by Elsevier Inc. • The American Journal of Medicine (2012) 125, 505-511 KEYWORDS: Central venous catheter-associated bloodstream infection; Chlorhexidine bathing; Healthcare-associated bloodstream infection. Reduction of healthcare-associated infections is a top priority for hospitals. In intensive care units, infection is com- mon and associated with significant morbidity and mortality.1 Healthcare-associated infections are often device- Presented in part at: the Society for Health Care Epidemiology of America 5th Decennial International Conference on Healthcare-Associated Infections, 2010, Atlanta, Georgia. Funding: New York State Department of Health Hospital-Acquired Infection Reporting Program. Interpretations of data do not necessarily represent interpretation or policy of the New York State Department of Health. Chlorhexidine cloths were provided by Sage Products Inc, Cary, Ill. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript. Reprint requests should be addressed to: Marisa A. Montecalvo, MD, Infection Prevention and Control, Macy Pavilion 2095, Westchester Medical Center, Valhalla, NY 10595. E-mail address: montecalvom@wcmc.com. 0002-9343/$ -see front matter © 2012 Published by Elsevier Inc. doi:10.1016/j.amjmed.2011.10.032 506 The American Journal of Medicine, Vol 125, No 5, May 2012 associated and can be caused by antibiotic-resistant pathogens that in Westchester County, New York. The study units were the flourish in the hospital environment. Preventing healthcare-assomedical intensive care unit of the tertiary care hospital, ciated infections requires rigorous infection control efforts that are which houses oncology and critically ill medical patients usually focused on the healthcare provider.2 A complementary but does not include trauma/surgical patients; the respirainfection control measure is to reduce the number of patients tory care unit of the tertiary care hospital, which houses colonized with a hospital pathogen medical and surgical patients rethrough decolonization strategies. quiring ongoing mechanical ventiThis is known as “source control,” but lation or respiratory care; and CLINICAL SIGNIFICANCE its use has been limited by few availmedical-surgical intensive care able modalities. units of the 4 community hospi● This 3-phase (pre-intervention, interBathing patients with the antiseptals, each of which houses a varivention [chlorhexidine bathing], posttic chlorhexidine is a potential tool for ety of critically ill medical and intervention), multiple-hospital study source control. The mechanism of ansurgical patients. found a statistically significant reductibacterial action involves attachment The study end point was hospition in central venous catheter-associof the positively charged chlorhexital-acquired central venous catheated bloodstream infection during chlordine to the negatively charged bacteter-associated bloodstream infechexidine bathing, and the reduction rial cell causing leakage of cytoplasm, tion rates. The inclusion criterion was sustained during the post-intervenresulting in bactericidal or bacteriofor chlorhexidine bathing was adtion period. static activity. Chlorhexidine reduces mission to the study unit. Excluboth resident and transient skin flora sion criteria were pregnancy, ● Chlorhexidine bathing was well tolewith a residual effect that lasts at least breast feeding, chlorhexidine alrated. 6 hours.3,4 lergy, and severely denuded skin. 5 ● Chlorhexidine bathing seems to be a usedemonstrated that The study was approved with a Vernon et al cleansing medical intensive care unit waiver for written informed conful adjunctive measure for reducing cenpatients with 2% chlorhexidine-satusent by the New York Medical tral venous catheter-associated bloodrated cloths resulted in significantly College Committee for Protection stream infection. fewer colonies of vancomycin-resisof Human Subjects and by the intant enterococci on patients’ skin and stitutional review board of each significantly less contamination of the hospital. environment and healthcare workers’ hands. The incidence of Phase 1 (pre-intervention) started April 1, 2008, at all acquisition of vancomycin-resistant enterococci was reduced by hospitals and lasted for 6 to 9 months on each unit; the 60%.5 Subsequently, studies of chlorhexidine bathing in the same different time intervals allowed units to transition to phase 2 separately. During phase 1, patients were bathed accordunit and in another medical intensive care unit found that the ing to hospital protocol; nonmedicated bathing cloths were period of chlorhexidine bathing was associated with significant 6 used at sites A, B, and E, and soap and water in a basin bath reductions in primary bloodstream infections and central venous 7 were used at sites C, D, and F. catheter-associated bloodstream infections. By using an alterna8 Phase 2 (active intervention) began immediately after tive method to the chlorhexidine saturated cloths, Climo et al evaluated the effect of adding 4% liquid chlorhexidine to paphase 1 and lasted for 8 months on each unit. During phase tients’ bath water. In that multiple-hospital study, there were 2, bathing was performed with 2% chlorhexidine gluconate significantly fewer vancomycin-resistant enterococcal bloodcloths (Sage Products Inc, Cary, Ill) provided to the hospital stream infections and fewer patients acquired vancomycinat no charge. The bathing protocol was to use 1 package of resistant enterococci and methicillin-resistant Staphylococcus 6 cloths with 1 cloth for each of the following anatomic aureus during the period of chlorhexidine bathing. areas: the neck/shoulders and chest, both arms and hands, To extend our understanding of the efficacy of chlorhexiabdomen/groin/perineum, right leg/foot, left leg/foot, and dine bathing, we performed a prospective, 3-phase, multiback and buttocks. If needed, more than 1 package was ple-hospital study designed to evaluate the effect of chloused. The face was cleansed with nonmedicated cloths. rhexidine bathing on central venous catheter-associated During the week before chlorhexidine bathing began, all bloodstream infection and the sustainability of any effect nursing staff received in-service education on bathing prodetected. In addition, skin tolerability and frequency of cedures, study requirements to record the chlorhexidine bathing were assessed during the active intervention period. baths administered on a research flow sheet, and how to assess skin tolerability (at each shift) in consultation with research personnel. Research personnel made rounds on all MATERIALS AND METHODS study units at least weekly. Study Design, End Points, and Setting Phase 3 (post-intervention) began immediately after The study was a prospective, 3-phase study performed from phase 2 and lasted for 12 months on each unit. During phase April 1, 2008, to August 31, 2010. This study was per3 hospitals could continue chlorhexidine bathing, but the formed at 1 tertiary care hospital and 4 community hospitals product was no longer supplied by the study. All 6 units Montecalvo et al Table 1 Chlorhexidine Bathing 507 Study Unit Characteristics During the Pre-Intervention, Active Intervention, and Post-Intervention Periods Average Length of Stay in Days* Unit Unit No. of Beds Unit Type Pre-Intervention Active Intervention Post-Intervention A B C D E F 7, 11† 20 12 5 10 12 Medical intensive care Respiratory care Medical surgical intensive Medical surgical intensive Medical surgical intensive Medical surgical intensive 6.1 16.6 4.4 4.7 4.9 7.3 6.4 16.8 5.2 5.7 5.4 8.0 6.0 11.2 4.9 4.6 7.3 6.9 care care care care *Derived from the number of patient days divided by the number of admissions. †On the first day of the active intervention period, the unit moved from a 7-bed unit to an 11-bed unit. chose to continue chlorhexidine bathing using the same product and bathing protocol. Research personnel kept track of whether chlorhexidine bathing was in use, but the baths administered were no longer recorded on research forms. Research personnel continued to be available for any questions regarding skin tolerability. Throughout all phases of the study, the Infection Prevention and Control Department at each site had policies and procedures in the intensive care unit that emphasized the importance of insertion checklists9 to reduce central venous catheter-associated bloodstream infection. During the pre-intervention period of the study, site C began using an antibiotic impregnated central venous catheter 5 months before chlorhexidine bathing began, and site D began using a chlorhexidine-impregnated central venous catheter dressing 3 months before chlorhexidine bathing began. Definitions All positive blood cultures were reviewed by infection prevention and control staff at each site and classified as central venous catheter-associated bloodstream infection and as hospital-acquired using the National Healthcare Safety Network of the Centers for Disease Control and Prevention definition.10 A central venous catheter-associated bloodstream infection was defined as a patient with a central venous catheter in place with a recognized pathogen cultured from one or more blood cultures AND the organism was not related to an infection at another site; or a common skin organism was cultured from 2 or more blood cultures drawn on separate occasions (within 2 days of each other) AND at least 1 of the following signs or symptoms was present: fever (⬎38°C), chills, or hypotension, AND the signs and symptoms and positive blood cultures were not due to infection at another site. Central venous catheterassociated bloodstream infection was defined as acquired on the study unit if the signs and symptoms of infection were not incubating at the time of admission and the positive blood culture was drawn while the patient was housed on the unit or within 48 hours of the time of discharge from the unit. The denominator for the central venous catheter-associated bloodstream infection rates was 1000 central venous catheter days. Days eligible for a bath included the day of admission to the unit, the day of discharge from the unit, and all days hospitalized on the unit. Statistical Methods The sample size estimate was derived from a known rate of 4 healthcare-associated bacteremias per 1000 patient days at the tertiary care medical center during the year before the study began. On the basis of published studies, it was assumed that chlorhexidine bathing would result in a 50% reduction of healthcare-associated bloodstream infection.6 To achieve a statistically significant reduction (P ⫽ .05) in central venous catheter-associated bloodstream infection with a power of 80%, the sample size estimate was 12,700 patient days each for the pre-intervention period and 12,700 patient days for the active intervention period. Infection rates were modeled over the 3 study periods using Poisson regression.11 In this approach, total infection counts are adjusted for total central venous catheter days, stratified by hospital and study period. Both hospital and study period were modeled using indicator variables. Results are expressed as adjusted incidence rate ratios with accompanying 95% confidence intervals (CIs). Pairwise comparison of rates over study periods was conducted using the Wald test with Bonferroni’s adjustment to the P value. We conducted a subanalysis that excluded the 2 sites (C and D) that had initiated parallel interventions that may have influenced study results. The subanalyses were conducted as described above. Analyses were conducted using Stata version 11.1 (StataCorp, College Station, Tex) and SAS version 9.1 (SAS Institute Inc, Cary, NC). A critical test level of 5% was considered statistically significant, unless adjusted for multiple comparisons. RESULTS The study unit characteristics, number of beds, and average length of stay during each period of the study are shown in Table 1. The number of patient days and the number of admissions for each study phase was 12,603 patient days, 1808 admissions for the pre-intervention period; 13,864 patient days, 1832 admissions for the active intervention period; and 19,914 patient days and 2834 admissions for the 508 The American Journal of Medicine, Vol 125, No 5, May 2012 Table 2 Rates of Central Venous Catheter-associated Bloodstream Infection During the Pre-Intervention, Active Intervention, and Post-Intervention Periods Active Intervention Chlorhexidine Bathing Post-Intervention* Chlorhexidine Bathing Central Venous Catheter Days Rate† No. of Central Venous Catheter-associated Bloodstream Infections Central Venous Catheter Days Rate No. of Central Venous Catheter-associated Bloodstream Infections Central Venous Catheter Days Rate 940 1688 717 205 1063 655 5268 9 14 0 0 2 0 25 1772 2022 646 397 943 686 6466 14 18 2 3 2 0 39 2892 2755 909 299 1457 976 9288 Pre-Intervention Site No. of Central Venous Catheter-associated Bloodstream Infections A 6 B 25 C 6 D 2 E 4 F 3 Total 46 Adjusted rate‡ 6.4 14.8 8.4 9.8 3.8 4.6 8.7 6.4 5.1 6.9 0.0 0.0 2.1 0.0 3.9 2.6 4.8 6.5 2.2 10.0 1.4 0 4.2 2.9 *Post-intervention all sites continued chlorhexidine bathing; sites E and F had periods of bathing without chlorhexidine of 4 and 5 months, respectively. †Rate ⫽ number of central venous catheter-associated bloodstream infections per 1000 central venous catheter days. ‡The central venous catheter-associated bloodstream infection rate is adjusted for total central venous catheter days, stratified by hospital and study period. days; relative risk [RR], 0.42, 95% CI, 0.25-0.68; P ⬍ .001) (Table 2). This reduction was sustained during the postintervention period (2.9/1000 central venous catheter days; RR, 0.46; 95% CI, 0.30-0.70; P ⬍ .001) (Figure 1). There was little difference in the rates of central venous catheterassociated bloodstream infection between the active intervention period and the post-intervention period (P ⫽ .9). During the lapse in chlorhexidine bath supply at sites E and F during the post-intervention period, 1 site had 2 infections (Table 2). These numbers were considered too small to reassess the chlorhexidine effect. A subanalysis was performed excluding sites C and D, which had begun using other products that may reduce central venous catheter- Central venous catheter-associated bloodstream infecon rate per 1000 central venous catheter days post-intervention period. On the first day of the active intervention period, site A moved the intensive care unit from a 7-bed unit to a new 11-bed unit. Exclusions from chlorhexidine bathing occurred for 2 patients during the active intervention period, 1 due to pregnancy and 1 due to StevensJohnson syndrome. Chlorhexidine bathing was discontinued in 3 patients because of skin rash and restarted in 2 of the 3 patients without adverse event; the third patient also had thrombocytopenia that resolved with the discontinuation of multiple medications and chlorhexidine. During the active intervention period, chlorhexidine baths were given on 12,196 (82%) of 14,942 days that patients were eligible for a bath. A total of 18,357 chlorhexidine baths were given, indicating an average of 1.5 chlorhexidine baths daily. The reasons recorded for not administering a chlorhexidine bath included the patient being admitted to or discharged from the unit that day (54% of missed baths) or unknown (46% of missed baths). During the post-intervention period, chlorhexidine baths were in use by study units for 17,519 (88%) of 19,914 post-intervention study days. Two units, E and F, did not use chlorhexidine for bathing for 4 and 5 months, respectively, because of lapses in product supply at the beginning of the post-intervention period when chlorhexidine baths were no longer provided by the study. Rates of central venous catheter-associated bloodstream infection, unadjusted and adjusted for study center, are shown in Table 2. Compared with the pre-intervention period adjusted rate (6.4/1000 central venous catheter days), there was a significant reduction in the rate of central venous catheter-associated bloodstream infection during the active intervention period (2.6/1000 central venous catheter 10 9 8 7 6 5 4 3 2 1 0 Pre-intervention Active Intervention Post-intervention Figure 1 Adjusted rates of central venous catheter-associated bloodstream infection with limits of the 95% CI range for each point estimate. Montecalvo et al Chlo ...
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Running Head: QUANTITATIVE RESEARCH CRITIQUE

Quantitative Research Critique
Student’s Name
University’s Name
Date of Submission

1

QUANTITATIVE RESEARCH CRITIQUE

2

Introduction
Nursing research is very important because it enhances the knowledge of nurses and
medical employees, as the role of nursing and medical employees is being so much focused on in
the current pandemic crisis, the medical and nursing research importance had been raised. In this
paper, two peer-reviewed, quantitative and same concept related article research will be
discussed, a PICOT question will be presented, discussed and answered using the two pieces of
research.
Quantitative Studies
The two quantitative pieces of research that are being APA referenced in the reference section,
are having these titles:


Chlorhexidine bathing to reduce central venous catheter-associated bloodstream
infection: impact and sustainability



The impact of chlorhexidine bathing on hospital-acquired bloodstream infections: a
systematic review and meta-analysis

Background
Both research articles had similar backgrounds, but the differences will be presented
later. The problem is that patients in hospitals are having infections acquired from the hospital
that was not present before the hospital stay. So the purpose would be reducing and minimizing
those acquired in...

Omartaha (3420)
Cornell University

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