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Designing Effective EBP Changes : Project Paper
NURS 4100, Quality and Safety Through Evidence Based Practice
July, 05,2020
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Designing Effective EBP Change
The Evidence-based practice (EBP) project paper describes a specific clinical issue that
needs a practice change starting with the formulation of a clinical question in the PICO format
and moving on to describe, evaluate and review the research-based evidence available for the
proposed practice change. The PICO question formulated for the EBP project paper is stated as
follows:
In medical-surgical patients with urinary retention, does intermittent catheterization
every 8 hours compared to placing an indwelling catheter result in the decrease in the number of
Catheter-Associated Urinary Tract Infections (CAUTIs)”
The purpose of this paper is to describe the strategies used for undertaking a practice
changed as guided by evidence. Based on the appraisal of the relevant scientific literature for the
clinical question and the PICO question, the paper describes the recommended change in practice
and the evaluation strategies used for the practice change project. The paper finally ends with a
conclusion.
Recommended Change in Practice
The PICO question relates to the incidence of Catheter-Associated Urinary Tract
Infections (CAUTIs). CAUTIs are one of the most commonly occurring hospitals acquired
infections experienced by patients while being hospitalized. Indwelling catheters have been
considered to be the most important implicating factor for CAUTIs (Gyesi-Appiah et al., 2020).
While being hospitalized, patients need urinary catheterization for various reasons including
certain disease processes, and disease-induced limitations for the patients. This demonstrates that
urinary catheterization is an unavoidable need while caring for patients in the settings of a
hospital, especially the medical-surgical units, where most of the admitted patients invariably
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need to be catheterized. However, the practice change which needs to be considered is to shift
from a method of catheterization which results in a high incidence of CAUTIs to a method that
results in lower chances of CAUTIs.
Keeping in view the need for a better method of catheterization, it is important to review
the types of catheterization techniques which can be used in the settings of a medical-surgical
unit. The most commonly used strategy for catheterization is the use of indwelling urinary
catheters. The catheter is inserted through the urethra and held in place for extended durations of
time by inflating the end of the catheter which anchors in the bladder. Being secured in its place,
the catheter can be used for a very long time, making it convenient for both the healthcare
service providers and the patients. In contrast, intermittent urinary catheters are used in a more
disposable fashion, whereby the catheter is inserted into the urethra several times each day for a
duration sufficient to drain the urinary bladder.
Although both strategies have their advantages and disadvantages, one of the most
important considerations which should be made while choosing between the alternative methods
and strategies of urinary catheterization includes the incidence of CAUTIs associated with the
use of the methods. CAUTIs cause significant morbidity and mortality in patients who suffer
from them. As such, it is the top priority of the healthcare service providers to choose a strategy
of catheterization which results in a lower incidence of CAUTIs.
The morbidity and mortality as a result of CAUTIs due to urinary catheterization are
demonstrated by the duration of hospitalization and the length of hospital stay. This is manifest
from the fact that patients acquiring CAUTIs take longer to regain their health for whatever
condition they were hospitalized. A study was undertaken by Al-Hazmi (2015) to prove the
hypothesis that the duration by which a patient is catheterized and stays in the hospital (length of
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stay, LOS at the hospital) has an association with the incidence (rate of occurrence) of the
Catheter-Associated Urinary Tract Infections (CA-UTIs). The main findings of the research
included that reducing the time duration by which a patient was catheterized and the length of
stay of the patient both had a positive effect on reducing the incidence of catheter-associated
urinary tract infections (CA-UTIs). Therefore, the evidence obtained from research by Al-Hazmi
(2015) dictated reducing the duration of catheterization which can practicably be done by
preferring intermittent catheterization over indwelling catheter use in the medical-surgical
patients.
Research by Mulder, Hakvoort, de Bruin, van der Post, & Roovers (2018) was
undertaken to determine the safety of either of the two methods of urinary catheterization,
intermittent or trans-urethral indwelling, in preventing the incidence of urinary tract infections
(UTIs) after the spontaneous vaginal deliveries in the hospital settings. The evidence provided by
the research demonstrated that in the subjects having post-partum urinary retention, the clean
intermittent catheterization was preferable to trans-urethral indwelling catheterization in
reducing the chance of catheter-associated urinary tract infections.
The superiority of intermittent catheterization was also proven by a systematic review of
randomized clinical trials (RCTs) undertaken by Zhang et al. (2015) which provided level 1
evidence for the superiority of intermittent catheterization compared to indwelling
catheterization in patients after undertaking Total Joint Arthroplasty. For those who are
catheterized using intermittent catheterization, Rognoni & Tarricone (2017) provided the
evidence recommending the use of hydrophilic catheters. The recommendation from Rognoni &
Tarricone (2017) was based on high-quality level 1 evidence furnished through a systematic
review of RCTs. Another recommended change in practice is that related to the prevention of
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CAUTIs in the patients admitted to the medical-surgical units by implementing educational
programs and daily checklist regarding maintaining the indwelling catheters in cases where
intermittent catheterization is not feasible to lower the risk of CAUTIs in such long-term
patients. The evidence for this practice changed was provided by a quasi-experimental study
undertaken by Menegueti et al. (2019).
Evaluation Strategies
The recommended change in practice shall be evaluated after it has been implemented.
This includes the collection of data of incidence before the recommended practice change is
made, and after the implementation to see the trend of incidence of CAUTI in the patients
admitted into medical-surgical units. If the incidence is reduced the results of the intervention
shall be evaluated to be positive, if there is no significant change in the incidence of CAUTIs,
thee intervention shall be evaluated to have a neutral impact. However, in case the incidence of
CAUTIs rises after the intervention, the impact of the intervention shall be evaluated as negative.
Song, Eaton, Gordon, Hoyle, & Doorenbos (2015) made the use of indicators for measuring the
effectiveness of the implementation of a nursing evidence-based practice change, similar to the
proposed mechanism of evaluation.
Conclusion
It is concluded that the evidence-based practice change project shall start with the
formulation of a PICO question which shall be followed by a comprehensive search of the
literature to identify the credible sources of evidence to dictate the practice change. Based on
these recommendations, a practice change is undertaken which is then evaluated by measuring
the indicators for practice change.
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References
Al-Hazmi H. (2015). Role of the duration of catheterization and length of hospital stay on the
rate of catheter-related hospital-acquired urinary tract infections. Research and reports in
urology, 7, 4147. https://doi.org/10.2147/RRU.S75419
Gyesi-Appiah, E., Brown, J., & Clifton, A. (2020). Short-term urinary catheters and their risks:
an integrated systematic review. British Journal Of Nursing, 29(9), S16-S22.
https://doi.org/10.12968/bjon.2020.29.9.s16
Menegueti, M. G., Ciol, M. A., Bellissimo-Rodrigues, F., Auxiliadora-Martins, M., Gaspar, G.
G., Canini, S., Basile-Filho, A., & Laus, A. M. (2019). Long-term prevention of catheter-
associated urinary tract infections among critically ill patients through the
implementation of an educational program and a daily checklist for maintenance of
indwelling urinary catheters: A quasi-experimental study. Medicine, 98(8), e14417.
https://doi.org/10.1097/MD.0000000000014417
Mulder, F., Hakvoort, R. A., de Bruin, J. P., van der Post, J., & Roovers, J. (2018). Comparison
of clean intermittent and transurethral indwelling catheterization for the treatment of
overt urinary retention after vaginal delivery: a multicentre randomized controlled
clinical trial. International urogynecology journal, 29(9), 12811287.
https://doi.org/10.1007/s00192-017-3452-y
Song, W., Eaton, L. H., Gordon, D. B., Hoyle, C., & Doorenbos, A. Z. (2015). Evaluation of
Evidence-based Nursing Pain Management Practice. Pain management nursing : official
journal of the American Society of Pain Management Nurses, 16(4), 456463.
https://doi.org/10.1016/j.pmn.2014.09.001
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Zhang, W., Liu, A., Hu, D., Xue, D., Li, C., Zhang, K., Ma, H., Yan, S., & Pan, Z. (2015).
Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty:
A Systematic Review and Meta-Analysis. PloS one, 10(7), e0130636.
https://doi.org/10.1371/journal.pone.0130636
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APPENDIX F
Appraisal Guide:
Findings of a Quantitative Study
APA Formatted Citation: (4 pts.)
Al-Hazmi H. (2015). Role of duration of catheterization and length of hospital stay on the rate of
catheter-related hospital-acquired urinary tract infections. Research and reports in
urology, 7, 4147. https://doi.org/10.2147/RRU.S75419
Synopsis (16 pts.)
1. What was the purpose of the study (research questions, purposes, and hypotheses)?
The purpose of the study by Al-Hazmi (2015)was proving the hypothesis that the
duration by which a patient is catheterized and stays in the hospital (length of stay, LOS
at the hospital) has an association with the incidence (rate of occurrence) of the Catheter-
Associated Urinary Tract Infections (CA-UTIs). The research questions pertained to the
type of catheter uses, intermittent, or indwelling, causative organisms, diagnosis at the
time of being admitted to the hospital, and the presence of comorbid conditions.
2. How was the sample obtained?
The sample was obtained by the use of non-probability purposive sampling technique to
identify a sample of 250 patients, who had an exposure of being catheterized and had
urinary tract infection.
3. What inclusion or exclusion criteria were used?
The inclusion criteria used by the researchers was that the patient had undergone
hospitalization in any medical/surgical ward of the hospital in the year 2010, having a
primary diagnosis different from that of urinary tract infection, having developed the
clinical manifestations of pyrexia and supra-pubic tenderness after being catheterized.
There were no peculiar exclusion criteria for the study based on age, gender, socio-
demographic or healthcare conditions.
4. Who from the sample actually participated or contributed data (demographic or clinical
profile and dropout rate)?
The research was undertaken on two hundred and fifty subjects (patients), all having
exposure to catheterization, and from these subjects, 100 had developed a catheter-
associated urinary tract infection. There were no dropouts from the study.
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5. What methods were used to collect data (e.g., sequence, timing, types of data, and
measures)?
Data collection was undertaken from the archives of the medical records of patients,
present within the medical records department and accessed physically by the
researchers.
6. Was an intervention tested?
No.
A. How was the sample size determined?
The researchers used non-probability purposive sampling to identify the sample. In
this technique, arbitrary sample size is used.
B. Were patients randomly assigned to treatment groups?
Since the research was not interventional or experimental in nature, patients were not
randomly assigned to the treatment or control groups.
7. What are the main findings of the study? (10 pts.)
The main findings of the research include that reducing the time duration by which a
patient was catheterized and the length of stay of the patient both had a positive effect on
reducing the incidence of catheter-associated urinary tract infections (CA-UTIs).
Credibility (14 pts.)
Yes
No
Not
Clear
Is the study published in a source that required peer review?
Yes
*Did the data obtained and the analysis conducted answer the
research question?
Yes
Were the measuring instruments reliable and valid?
Yes
*Were important extraneous variables and bias controlled?
Yes
*If an intervention was tested, answer the following five
questions:
Were participants randomly assigned to groups and were
the two groups similar at the start (before the
intervention)?
No
Were the interventions well defined and consistently
delivered?
No
Were the groups treated equally other than the difference in
interventions?
No
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If no difference was found, was the sample size large
enough to detect a difference if one existed?
No
If a difference was found, are you confident it was due to
the intervention?
No
Are the findings consistent with findings from other studies?
All
Some
No
ARE THE FINDINGS CREDIBLE?
Yes
Clinical Significance (6 pts.)
1. Note any difference in means, r
2
s, or measures of clinical effects (ABI, NNT, RR, OR)
Answer Here: RR
Yes
No
Not
Clear
*Is the target population clearly described?
Yes
*Is the frequency, association, or treatment effect impressive
enough for you to be confident that the finding would make a
clinical difference if used as the basis for care?
Yes
All
Some
No
ARE THE FINDINGS CLINICALLY
SIGNIFICANT?
Yes
*= Important criteria
Comments
The article describes the association of the incidence of catheter-associated urinary tract
infections (CA-UTIs) with the duration of the catheterization, and the length of stay in the
hospital quite well based on a quantitative descriptive approach.
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APPENDIX F
Appraisal Guide:
Findings of a Quantitative Study
APA Formatted Citation: (4 pts.)
Mulder, F., Hakvoort, R. A., de Bruin, J. P., van der Post, J., & Roovers, J. (2018). Comparison
of clean intermittent and transurethral indwelling catheterization for the treatment of
overt urinary retention after vaginal delivery: a multicentre randomized controlled
clinical trial. International urogynecology journal, 29(9), 12811287.
https://doi.org/10.1007/s00192-017-3452-y
Synopsis (16 pts.)
1.What was the purpose of the study (research questions, purposes, and hypotheses)?
The purpose of the study by Mulder et al. (2018) was to determine the safety of either of
the two methods of urinary catheterization, intermittent or trans-urethral indwelling, in
preventing the incidence of urinary tract infections (UTIs) after the spontaneous vaginal
deliveries in the hospital settings. The research questions pertained to determining the
superiority of the two catheterization interventions over each other in the over-distension
in the patients having post-partum urinary retention, reduction in the duration of the
patient being catheterized, and urinary outcomes after three months of the delivery.
2.How was the sample obtained?
The sample was obtained by the use of a probability simple random sampling technique
to identify a sample of 68 patients, 34 in each of the two groups.
3. What inclusion or exclusion criteria were used?
The researchers did not specify the use of a specific inclusion or exclusion criteria for
their research.
4. Who from the sample actually participated or contributed data (demographic or clinical
profile and dropout rate)?
The research was undertaken on 68 subjects (patients), 34 undergoing intermittent
catheterization, and 34 undergoing indwelling catheterization. There were no dropouts
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from the study. The researchers initially used 86 subjects for their study assuming the
drop-out rate to be fifteen percent.
5. What methods were used to collect data (e.g., sequence, timing, types of data, and
measures)?
Data collection was undertaken by the researchers personally after undertaking the
appropriate interventions based upon catheterization protocols. The data was quantitative,
and there were no specific measures.
6. Was an intervention tested?
Yes
A How was the sample size determined?
The researchers used the difference between the 2 treatment groups of 6 points related
to the Obstructive Micturition Domain to calculate the sample size. They used to the
power of 80 %, α=0.05, and S.D. =3.75 for the sample size calculation.
B. Were patients randomly assigned to treatment groups?
Randomization was undertaken to assign the patients to each of the treatment groups.
7. What are the main findings of the study? (10 pts.)
The key finding of the research was that in the subjects having post-partum urinary
retention, the clean intermittent catheterization was preferable to trans-urethral indwelling
catheterization in reducing the chance of catheter-associated urinary tract infections.
Credibility (14 pts.)
Yes
No
Not
Clear
Is the study published in a source that required peer review?
Yes
*Did the data obtained and the analysis conducted answer the
research question?
Yes
Were the measuring instruments reliable and valid?
Yes
*Were important extraneous variables and bias controlled?
Yes
*If an intervention was tested, answer the following five
questions:
Were participants randomly assigned to groups and were
the two groups similar at the start (before the
intervention)?
Yes
Were the interventions well defined and consistently
delivered?
Yes
Were the groups treated equally other than the difference in
interventions?
Yes
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If no difference was found, was the sample size large
enough to detect a difference if one existed?
Yes
If a difference was found, are you confident it was due to
the intervention?
Yes
Are the findings consistent with findings from other studies?
All
Some
No
ARE THE FINDINGS CREDIBLE?
Yes
Clinical Significance (6 pts.)
1. Note any difference in means, r
2
s, or measures of clinical effects (ABI, NNT, RR, OR)
Answer Here: NNT
Yes
No
Not
Clear
*Is the target population clearly described?
Yes
*Is the frequency, association, or treatment effect impressive
enough for you to be confident that the finding would make a
clinical difference if used as the basis for care?
Yes
All
Some
No
ARE THE FINDINGS CLINICALLY
SIGNIFICANT?
Yes
*= Important criteria
Comments
The article compares the two interventions in catheterization very well.
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APPENDIX C
Appraisal Guide:
Conclusions of a Systematic Review with Narrative Synthesis
APA Formatted Citation:
Zhang, W., Liu, A., Hu, D., Xue, D., Li, C., Zhang, K., Ma, H., Yan, S., & Pan, Z. (2015).
Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty:
A Systematic Review and Meta-Analysis. PloS one, 10(7), e0130636.
https://doi.org/10.1371/journal.pone.0130636
Synopsis
1. What organizations or persons produced the systematic review (SR)?
The systematic review was undertaken by Zhang et al. (2015)
2 How many persons were involved in conducting the review?
Nine people were involved in conducting the review.
3 What topic or question did the SR address?
The appraisal compared indwelling catheterization versus intermittent catheterization after total
joint arthroplasty for the rates of CAUTIs.
4 How were potential research reports identified?
The research reports were identified by the use of scientific databases like Cochrane Library,
PubMed and Embase.
5 What determined if a study was included in the analysis?
The inclusion criteria included those studies which were based on human subjects, the primary
intervention was total joint arthroplasty, and in those in which comparisons between intermittent
and indwelling catheterization were used.
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6 How many studies were included in the review?
Nine studies were reviewed.
7 What research designs were used in the studies?
Randomized Controlled Trial (RCT) research design was used in these studies.
8 What were the consistent and important across-studies conclusions?
The consistent and important conclusion across studies was the lower incidence of CAUTI with
the use of intermittent catheterization.
Yes
No
Not
Clear
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Which conclusions were supported by consistent findings from two or more good or high-quality
studies? List
The consistent and important conclusion across studies was the lower incidence of CAUTI with
the use of intermittent catheterization.
All
Some
No
Yes
No
Not
Clear
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Yes
Yes
All
Some
No
Yes
Yes
Yes
Yes
What changes, additions, training or purchases would be needed to implement and sustain a
clinical protocol based on these conclusions? Specify
No changes, additions, training or purchases are required. The recommendations can be used
within the existing framework of resources.
Yes
No
Not
Clear
Yes
How will we know if our patients are benefiting from our new protocol? Specify
By undertaking an evaluation of the outcomes.
All
Some
No
Yes
Yes
Comments
The systematic review provides excellent practice change recommendations for the EBP project.
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APPENDIX C
Appraisal Guide:
Conclusions of a Systematic Review with Narrative Synthesis
APA Formatted Citation:
Rognoni, C., & Tarricone, R. (2017). Intermittent catheterisation with hydrophilic and non-
hydrophilic urinary catheters: systematic literature review and meta-analyses. BMC
urology, 17(1), 4. https://doi.org/10.1186/s12894-016-0191-1
Synopsis
1 What organizations or persons produced the systematic review (SR)?
The systematic review was undertaken by Rognoni & Tarricone (2017).
2 How many persons were involved in conducting the review?
Two people were involved in conducting the review.
3 What topic or question did the SR address?
The appraisal compared intermittent catheterization with hydrophilic and non-hydrophilic
catheters for the rates of CAUTIs.
4 How were the potential research reports identified?
The research reports were identified by the use of scientific databases like Cochrane Library,
MEDLINE/PubMed and EMBASE.
5 What determined if a study was included in the analysis?
The inclusion criteria included those studies which were based on adult and adolescent subjects
having dysfunctional bladder requiring catheterization, with interventions comprising use of
hydrophilic catheters, comparison with non-hydrophilic catheters, and outcome being CAUTI.
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6 How many studies were included in the review?
Seven studies were reviewed.
7 What research designs were used in the studies?
Randomized Controlled Trial (RCT) research design was used in these studies.
8 What were the consistent and important across-study’s conclusions?
The consistent and important conclusion across studies was the effectiveness of hydrophilic
catheters in preventing CAUTIs.
Yes
No
Not
Clear
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Which conclusions were supported by consistent findings from two or more good or high-quality
studies? List
The consistent and important conclusion across studies was the lower incidence of CAUTI with
the use of intermittent catheterization.
All
Some
No
Yes
No
Not
Clear
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Yes
Yes
All
Some
No
Yes
Yes
Yes
Yes
What changes, additions, training or purchases would be needed to implement and sustain a
clinical protocol based on these conclusions? Specify
No changes, additions, training or purchases are required. The recommendations can be used
within the existing framework of resources.
Yes
No
Not
Clear
Yes
How will we know if our patients are benefiting from our new protocol? Specify
By evaluating the outcomes.
All
Some
No
Yes
Yes
Comments
The systematic review provides excellent practice change recommendations for the EBP project.
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APPENDIX F
Appraisal Guide:
Findings of a Quantitative Study
APA Formatted Citation: (4 pts.)
Menegueti, M. G., Ciol, M. A., Bellissimo-Rodrigues, F., Auxiliadora-Martins, M., Gaspar, G.
G., Canini, S., Basile-Filho, A., & Laus, A. M. (2019). Long-term prevention of catheter-
associated urinary tract infections among critically ill patients through the
implementation of an educational program and a daily checklist for maintenance of
indwelling urinary catheters: A quasi-experimental study. Medicine, 98(8), e14417.
https://doi.org/10.1097/MD.0000000000014417
Synopsis (16 pts.)
1. What was the purpose of the study (research questions, purposes, and hypotheses)?
The purpose of the study by Menegueti et al. (2019) was the evaluation of the impact of
implementation of health care providers educational program as well a daily checklist for
the use of indwelling catheters in the patients having critical illnesses in reducing the
incidence of CAUTIs.
2. How was the sample obtained?
The researchers did not do sampling. Instead, they used a twelve years period for their
intervention.
3 What inclusion or exclusion criteria were used?
The researchers did not specify the use of a specific inclusion or exclusion criteria for
their research.
4 Who from the sample actually participated or contributed data (demographic or clinical
profile and dropout rate)?
The research was undertaken by the researchers themselves.
5 What methods were used to collect data (e.g., sequence, timing, types of data, and
measures)?
Data collection was undertaken by the researchers personally after applying the protocol
designed for the researchers.
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6 Was an intervention tested?
Yes, the study comprised testing of an intervention.
A How was the sample size determined?
The researchers did not use a sample, and data collection was time-based instead.
C. Were patients randomly assigned to treatment groups?
Randomization was not undertaken by the researchers.
7 What are the main findings of the study? (10 pts.)
The key finding of the research was that healthcare service providers’ education as well
as daily evaluation of indwelling urinary catheter indications had extreme effectiveness in
reducing the rates of catheter utilization as well as the incidence density of CAUTI.
Credibility (14 pts.)
Yes
No
Not
Clear
Is the study published in a source that required peer review?
Yes
*Did the data obtained and the analysis conducted answer the
research question?
Yes
Were the measuring instruments reliable and valid?
Yes
*Were important extraneous variables and bias controlled?
Yes
*If an intervention was tested, answer the following five
questions:
Were participants randomly assigned to groups and were
the two groups similar at the start (before the
intervention)?
No
Were the interventions well defined and consistently
delivered?
Yes
Were the groups treated equally other than the difference in
interventions?
Yes
If no difference was found, was the sample size large
enough to detect a difference if one existed?
Yes
If a difference was found, are you confident it was due to
the intervention?
Yes
Are the findings consistent with findings from other studies?
All
Some
No
ARE THE FINDINGS CREDIBLE?
Yes
Clinical Significance (6 pts.)
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8 Note any difference in means, r
2
s, or measures of clinical effects (ABI, NNT, RR, OR)
Answer Here: NNT
Yes
No
Not
Clear
*Is the target population clearly described?
Yes
*Is the frequency, association, or treatment effect impressive
enough for you to be confident that the finding would make a
clinical difference if used as the basis for care?
Yes
All
Some
No
ARE THE FINDINGS CLINICALLY
SIGNIFICANT?
Yes
*= Important criteria
Comments
The article provides good quality evidence supporting the reduction of CAUTIs with an
educational intervention.

Unformatted Attachment Preview

1 Designing Effective EBP Changes : Project Paper NURS 4100, Quality and Safety Through Evidence Based Practice July, 05,2020 2 Designing Effective EBP Change The Evidence-based practice (EBP) project paper describes a specific clinical issue that needs a practice change starting with the formulation of a clinical question in the PICO format and moving on to describe, evaluate and review the research-based evidence available for the proposed practice change. The PICO question formulated for the EBP project paper is stated as follows: “In medical-surgical patients with urinary retention, does intermittent catheterization every 8 hours compared to placing an indwelling catheter result in the decrease in the number of Catheter-Associated Urinary Tract Infections (CAUTIs)” The purpose of this paper is to describe the strategies used for undertaking a practice changed as guided by evidence. Based on the appraisal of the relevant scientific literature for the clinical question and the PICO question, the paper describes the recommended change in practice and the evaluation strategies used for the practice change project. The paper finally ends with a conclusion. Recommended Change in Practice The PICO question relates to the incidence of Catheter-Associated Urinary Tract Infections (CAUTIs). CAUTIs are one of the most commonly occurring hospitals acquired infections experienced by patients while being hospitalized. Indwelling catheters have been considered to be the most important implicating factor for CAUTIs (Gyesi-Appiah et al., 2020). While being hospitalized, patients need urinary catheterization for various reasons including certain disease processes, and disease-induced limitations for the patients. This demonstrates that urinary catheterization is an unavoidable need while caring for patients in the settings of a hospital, especially the medical-surgical units, where most of the admitted patients invariably 3 need to be catheterized. However, the practice change which needs to be considered is to shift from a method of catheterization which results in a high incidence of CAUTIs to a method that results in lower chances of CAUTIs. Keeping in view the need for a better method of catheterization, it is important to review the types of catheterization techniques which can be used in the settings of a medical-surgical unit. The most commonly used strategy for catheterization is the use of indwelling urinary catheters. The catheter is inserted through the urethra and held in place for extended durations of time by inflating the end of the catheter which anchors in the bladder. Being secured in its place, the catheter can be used for a very long time, making it convenient for both the healthcare service providers and the patients. In contrast, intermittent urinary catheters are used in a more disposable fashion, whereby the catheter is inserted into the urethra several times each day for a duration sufficient to drain the urinary bladder. Although both strategies have their advantages and disadvantages, one of the most important considerations which should be made while choosing between the alternative methods and strategies of urinary catheterization includes the incidence of CAUTIs associated with the use of the methods. CAUTIs cause significant morbidity and mortality in patients who suffer from them. As such, it is the top priority of the healthcare service providers to choose a strategy of catheterization which results in a lower incidence of CAUTIs. The morbidity and mortality as a result of CAUTIs due to urinary catheterization are demonstrated by the duration of hospitalization and the length of hospital stay. This is manifest from the fact that patients acquiring CAUTIs take longer to regain their health for whatever condition they were hospitalized. A study was undertaken by Al-Hazmi (2015) to prove the hypothesis that the duration by which a patient is catheterized and stays in the hospital (length of 4 stay, LOS at the hospital) has an association with the incidence (rate of occurrence) of the Catheter-Associated Urinary Tract Infections (CA-UTIs). The main findings of the research included that reducing the time duration by which a patient was catheterized and the length of stay of the patient both had a positive effect on reducing the incidence of catheter-associated urinary tract infections (CA-UTIs). Therefore, the evidence obtained from research by Al-Hazmi (2015) dictated reducing the duration of catheterization which can practicably be done by preferring intermittent catheterization over indwelling catheter use in the medical-surgical patients. Research by Mulder, Hakvoort, de Bruin, van der Post, & Roovers (2018) was undertaken to determine the safety of either of the two methods of urinary catheterization, intermittent or trans-urethral indwelling, in preventing the incidence of urinary tract infections (UTIs) after the spontaneous vaginal deliveries in the hospital settings. The evidence provided by the research demonstrated that in the subjects having post-partum urinary retention, the clean intermittent catheterization was preferable to trans-urethral indwelling catheterization in reducing the chance of catheter-associated urinary tract infections. The superiority of intermittent catheterization was also proven by a systematic review of randomized clinical trials (RCTs) undertaken by Zhang et al. (2015) which provided level 1 evidence for the superiority of intermittent catheterization compared to indwelling catheterization in patients after undertaking Total Joint Arthroplasty. For those who are catheterized using intermittent catheterization, Rognoni & Tarricone (2017) provided the evidence recommending the use of hydrophilic catheters. The recommendation from Rognoni & Tarricone (2017) was based on high-quality level 1 evidence furnished through a systematic review of RCTs. Another recommended change in practice is that related to the prevention of 5 CAUTIs in the patients admitted to the medical-surgical units by implementing educational programs and daily checklist regarding maintaining the indwelling catheters in cases where intermittent catheterization is not feasible to lower the risk of CAUTIs in such long-term patients. The evidence for this practice changed was provided by a quasi-experimental study undertaken by Menegueti et al. (2019). Evaluation Strategies The recommended change in practice shall be evaluated after it has been implemented. This includes the collection of data of incidence before the recommended practice change is made, and after the implementation to see the trend of incidence of CAUTI in the patients admitted into medical-surgical units. If the incidence is reduced the results of the intervention shall be evaluated to be positive, if there is no significant change in the incidence of CAUTIs, thee intervention shall be evaluated to have a neutral impact. However, in case the incidence of CAUTIs rises after the intervention, the impact of the intervention shall be evaluated as negative. Song, Eaton, Gordon, Hoyle, & Doorenbos (2015) made the use of indicators for measuring the effectiveness of the implementation of a nursing evidence-based practice change, similar to the proposed mechanism of evaluation. Conclusion It is concluded that the evidence-based practice change project shall start with the formulation of a PICO question which shall be followed by a comprehensive search of the literature to identify the credible sources of evidence to dictate the practice change. Based on these recommendations, a practice change is undertaken which is then evaluated by measuring the indicators for practice change. 6 References Al-Hazmi H. (2015). Role of the duration of catheterization and length of hospital stay on the rate of catheter-related hospital-acquired urinary tract infections. Research and reports in urology, 7, 41–47. https://doi.org/10.2147/RRU.S75419 Gyesi-Appiah, E., Brown, J., & Clifton, A. (2020). Short-term urinary catheters and their risks: an integrated systematic review. British Journal Of Nursing, 29(9), S16-S22. https://doi.org/10.12968/bjon.2020.29.9.s16 Menegueti, M. G., Ciol, M. A., Bellissimo-Rodrigues, F., Auxiliadora-Martins, M., Gaspar, G. G., Canini, S., Basile-Filho, A., & Laus, A. M. (2019). Long-term prevention of catheterassociated urinary tract infections among critically ill patients through the implementation of an educational program and a daily checklist for maintenance of indwelling urinary catheters: A quasi-experimental study. Medicine, 98(8), e14417. https://doi.org/10.1097/MD.0000000000014417 Mulder, F., Hakvoort, R. A., de Bruin, J. P., van der Post, J., & Roovers, J. (2018). Comparison of clean intermittent and transurethral indwelling catheterization for the treatment of overt urinary retention after vaginal delivery: a multicentre randomized controlled clinical trial. International urogynecology journal, 29(9), 1281–1287. https://doi.org/10.1007/s00192-017-3452-y Song, W., Eaton, L. H., Gordon, D. B., Hoyle, C., & Doorenbos, A. Z. (2015). Evaluation of Evidence-based Nursing Pain Management Practice. Pain management nursing : official journal of the American Society of Pain Management Nurses, 16(4), 456–463. https://doi.org/10.1016/j.pmn.2014.09.001 7 Zhang, W., Liu, A., Hu, D., Xue, D., Li, C., Zhang, K., Ma, H., Yan, S., & Pan, Z. (2015). Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. PloS one, 10(7), e0130636. https://doi.org/10.1371/journal.pone.0130636 8 APPENDIX F Appraisal Guide: Findings of a Quantitative Study APA Formatted Citation: (4 pts.) Al-Hazmi H. (2015). Role of duration of catheterization and length of hospital stay on the rate of catheter-related hospital-acquired urinary tract infections. Research and reports in urology, 7, 41–47. https://doi.org/10.2147/RRU.S75419 Synopsis (16 pts.) 1. What was the purpose of the study (research questions, purposes, and hypotheses)? The purpose of the study by Al-Hazmi (2015)was proving the hypothesis that the duration by which a patient is catheterized and stays in the hospital (length of stay, LOS at the hospital) has an association with the incidence (rate of occurrence) of the CatheterAssociated Urinary Tract Infections (CA-UTIs). The research questions pertained to the type of catheter uses, intermittent, or indwelling, causative organisms, diagnosis at the time of being admitted to the hospital, and the presence of comorbid conditions. 2. How was the sample obtained? The sample was obtained by the use of non-probability purposive sampling technique to identify a sample of 250 patients, who had an exposure of being catheterized and had urinary tract infection. 3. What inclusion or exclusion criteria were used? The inclusion criteria used by the researchers was that the patient had undergone hospitalization in any medical/surgical ward of the hospital in the year 2010, having a primary diagnosis different from that of urinary tract infection, having developed the clinical manifestations of pyrexia and supra-pubic tenderness after being catheterized. There were no peculiar exclusion criteria for the study based on age, gender, sociodemographic or healthcare conditions. 4. Who from the sample actually participated or contributed data (demographic or clinical profile and dropout rate)? The research was undertaken on two hundred and fifty subjects (patients), all having exposure to catheterization, and from these subjects, 100 had developed a catheterassociated urinary tract infection. There were no dropouts from the study. 9 5. What methods were used to collect data (e.g., sequence, timing, types of data, and measures)? Data collection was undertaken from the archives of the medical records of patients, present within the medical records department and accessed physically by the researchers. 6. Was an intervention tested? No. A. How was the sample size determined? The researchers used non-probability purposive sampling to identify the sample. In this technique, arbitrary sample size is used. B. Were patients randomly assigned to treatment groups? Since the research was not interventional or experimental in nature, patients were not randomly assigned to the treatment or control groups. 7. What are the main findings of the study? (10 pts.) The main findings of the research include that reducing the time duration by which a patient was catheterized and the length of stay of the patient both had a positive effect on reducing the incidence of catheter-associated urinary tract infections (CA-UTIs). Credibility (14 pts.) Is the study published in a source that required peer review? Yes No Yes *Did the data obtained and the analysis conducted answer the Yes research question? Were the measuring instruments reliable and valid? Yes *Were important extraneous variables and bias controlled? Yes *If an intervention was tested, answer the following five questions: Were participants randomly assigned to groups and were the two groups similar at the start (before the intervention)? Were the interventions well defined and consistently delivered? Were the groups treated equally other than the difference in interventions? No No No Not Clear 10 If no difference was found, was the sample size large enough to detect a difference if one existed? If a difference was found, are you confident it was due to the intervention? Are the findings consistent with findings from other studies? No No All ARE THE FINDINGS CREDIBLE? Some No Yes Clinical Significance (6 pts.) 1. Note any difference in means, r2s, or measures of clinical effects (ABI, NNT, RR, OR) Answer Here: RR Yes *Is the target population clearly described? *Is the frequency, association, or treatment effect impressive enough for you to be confident that the finding would make a clinical difference if used as the basis for care? ARE THE FINDINGS CLINICALLY SIGNIFICANT? *= No Not Clear Some No Yes Yes All Yes Important criteria Comments The article describes the association of the incidence of catheter-associated urinary tract infections (CA-UTIs) with the duration of the catheterization, and the length of stay in the hospital quite well based on a quantitative descriptive approach. 11 APPENDIX F Appraisal Guide: Findings of a Quantitative Study APA Formatted Citation: (4 pts.) Mulder, F., Hakvoort, R. A., de Bruin, J. P., van der Post, J., & Roovers, J. (2018). Comparison of clean intermittent and transurethral indwelling catheterization for the treatment of overt urinary retention after vaginal delivery: a multicentre randomized controlled clinical trial. International urogynecology journal, 29(9), 1281–1287. https://doi.org/10.1007/s00192-017-3452-y Synopsis (16 pts.) 1.What was the purpose of the study (research questions, purposes, and hypotheses)? The purpose of the study by Mulder et al. (2018) was to determine the safety of either of the two methods of urinary catheterization, intermittent or trans-urethral indwelling, in preventing the incidence of urinary tract infections (UTIs) after the spontaneous vaginal deliveries in the hospital settings. The research questions pertained to determining the superiority of the two catheterization interventions over each other in the over-distension in the patients having post-partum urinary retention, reduction in the duration of the patient being catheterized, and urinary outcomes after three months of the delivery. 2.How was the sample obtained? The sample was obtained by the use of a probability simple random sampling technique to identify a sample of 68 patients, 34 in each of the two groups. 3. What inclusion or exclusion criteria were used? The researchers did not specify the use of a specific inclusion or exclusion criteria for their research. 4. Who from the sample actually participated or contributed data (demographic or clinical profile and dropout rate)? The research was undertaken on 68 subjects (patients), 34 undergoing intermittent catheterization, and 34 undergoing indwelling catheterization. There were no dropouts 12 from the study. The researchers initially used 86 subjects for their study assuming the drop-out rate to be fifteen percent. 5. What methods were used to collect data (e.g., sequence, timing, types of data, and measures)? Data collection was undertaken by the researchers personally after undertaking the appropriate interventions based upon catheterization protocols. The data was quantitative, and there were no specific measures. 6. Was an intervention tested? Yes A How was the sample size determined? The researchers used the difference between the 2 treatment groups of 6 points related to the Obstructive Micturition Domain to calculate the sample size. They used to the power of 80 %, α=0.05, and S.D. =3.75 for the sample size calculation. B. Were patients randomly assigned to treatment groups? Randomization was undertaken to assign the patients to each of the treatment groups. 7. What are the main findings of the study? (10 pts.) The key finding of the research was that in the subjects having post-partum urinary retention, the clean intermittent catheterization was preferable to trans-urethral indwelling catheterization in reducing the chance of catheter-associated urinary tract infections. Credibility (14 pts.) Yes Is the study published in a source that required peer review? Yes *Did the data obtained and the analysis conducted answer the research question? Were the measuring instruments reliable and valid? *Were important extraneous variables and bias controlled? *If an intervention was tested, answer the following five questions: Were participants randomly assigned to groups and were the two groups similar at the start (before the intervention)? Were the interventions well defined and consistently delivered? Were the groups treated equally other than the difference in interventions? Yes Yes Yes Yes Yes Yes No Not Clear 13 If no difference was found, was the sample size large enough to detect a difference if one existed? If a difference was found, are you confident it was due to the intervention? Are the findings consistent with findings from other studies? Yes Yes All ARE THE FINDINGS CREDIBLE? Some No Yes Clinical Significance (6 pts.) 1. Note any difference in means, r2s, or measures of clinical effects (ABI, NNT, RR, OR) Answer Here: NNT Yes *Is the target population clearly described? *Is the frequency, association, or treatment effect impressive enough for you to be confident that the finding would make a clinical difference if used as the basis for care? ARE THE FINDINGS CLINICALLY SIGNIFICANT? *= No Not Clear Some No Yes Yes All Yes Important criteria Comments The article compares the two interventions in catheterization very well. 14 APPENDIX C Appraisal Guide: Conclusions of a Systematic Review with Narrative Synthesis APA Formatted Citation: Zhang, W., Liu, A., Hu, D., Xue, D., Li, C., Zhang, K., Ma, H., Yan, S., & Pan, Z. (2015). Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. PloS one, 10(7), e0130636. https://doi.org/10.1371/journal.pone.0130636 Synopsis 1. What organizations or persons produced the systematic review (SR)? The systematic review was undertaken by Zhang et al. (2015) 2 How many persons were involved in conducting the review? Nine people were involved in conducting the review. 3 What topic or question did the SR address? The appraisal compared indwelling catheterization versus intermittent catheterization after total joint arthroplasty for the rates of CAUTIs. 4 How were potential research reports identified? The research reports were identified by the use of scientific databases like Cochrane Library, PubMed and Embase. 5 What determined if a study was included in the analysis? The inclusion criteria included those studies which were based on human subjects, the primary intervention was total joint arthroplasty, and in those in which comparisons between intermittent and indwelling catheterization were used. 15 6 How many studies were included in the review? Nine studies were reviewed. 7 What research designs were used in the studies? Randomized Controlled Trial (RCT) research design was used in these studies. 8 What were the consistent and important across-studies conclusions? The consistent and important conclusion across studies was the lower incidence of CAUTI with the use of intermittent catheterization. Credibility Was the topic clearly defined? Was the search for studies and other evidence comprehensive and unbiased? Was the screening of citations for Inclusion based on explicit criteria? *Were the included studies assessed for quality? Were the design characteristics and findings of the included studies displayed or discussed in sufficient detail? *Was there a true integration (i.e., synthesis) of the findings- not merely reporting of findings from each study individually? *Did the reviewers explore why differences in findings might have occurred? Did the reviewers distinguish between conclusions based on consistent findings from several good studies and those based on inferior evidence (number or quality)? Yes No Not Clear Yes Yes Yes Yes Yes Yes Yes Yes Which conclusions were supported by consistent findings from two or more good or high-quality studies? List The consistent and important conclusion across studies was the lower incidence of CAUTI with the use of intermittent catheterization. ARE THE CONSLUSIONS CREDIBLE? Clinical Significance All Some No Yes No Not Clear 16 *Across studies, is the size of the treatment or the strength of the association found or the meaningfulness of qualitative findings strong enough to make a difference in patient outcomes or experiences of care? Are the conclusions relevant to the care the nurse gives? Yes Yes All ARE THE CONCLUSIONS CLINICALLY SIGNIFICANT? Yes Applicability Yes Does the SR address a problem, situation, or decision we are addressing in our setting? Are the patients in the studies or a subgroup of patients in the studies similar to those we see? Yes Some No Yes What changes, additions, training or purchases would be needed to implement and sustain a clinical protocol based on these conclusions? Specify No changes, additions, training or purchases are required. The recommendations can be used within the existing framework of resources. Yes Is what we will have to do to implement the new protocol realistically achievable by us (resources, capability, commitment)? No Not Clear Yes How will we know if our patients are benefiting from our new protocol? Specify By undertaking an evaluation of the outcomes. All ARE THESE CONCLUSIONS APPLICABLE TO OUR SETTING? SHOULD WE PROCEED TO DESIGN A PROTOCO INCORPORATING THESE CONCLUSIONS? Some No Yes Yes Comments The systematic review provides excellent practice change recommendations for the EBP project. 17 APPENDIX C Appraisal Guide: Conclusions of a Systematic Review with Narrative Synthesis APA Formatted Citation: Rognoni, C., & Tarricone, R. (2017). Intermittent catheterisation with hydrophilic and nonhydrophilic urinary catheters: systematic literature review and meta-analyses. BMC urology, 17(1), 4. https://doi.org/10.1186/s12894-016-0191-1 Synopsis 1 What organizations or persons produced the systematic review (SR)? The systematic review was undertaken by Rognoni & Tarricone (2017). 2 How many persons were involved in conducting the review? Two people were involved in conducting the review. 3 What topic or question did the SR address? The appraisal compared intermittent catheterization with hydrophilic and non-hydrophilic catheters for the rates of CAUTIs. 4 How were the potential research reports identified? The research reports were identified by the use of scientific databases like Cochrane Library, MEDLINE/PubMed and EMBASE. 5 What determined if a study was included in the analysis? The inclusion criteria included those studies which were based on adult and adolescent subjects having dysfunctional bladder requiring catheterization, with interventions comprising use of hydrophilic catheters, comparison with non-hydrophilic catheters, and outcome being CAUTI. 18 6 How many studies were included in the review? Seven studies were reviewed. 7 What research designs were used in the studies? Randomized Controlled Trial (RCT) research design was used in these studies. 8 What were the consistent and important across-study’s conclusions? The consistent and important conclusion across studies was the effectiveness of hydrophilic catheters in preventing CAUTIs. Credibility Was the topic clearly defined? Was the search for studies and other evidence comprehensive and unbiased? Was the screening of citations for Inclusion based on explicit criteria? *Were the included studies assessed for quality? Were the design characteristics and findings of the included studies displayed or discussed in sufficient detail? *Was there a true integration (i.e., synthesis) of the findings- not merely reporting of findings from each study individually? *Did the reviewers explore why differences in findings might have occurred? Did the reviewers distinguish between conclusions based on consistent findings from several good studies and those based on inferior evidence (number or quality)? Yes No Not Clear Yes Yes Yes Yes Yes Yes Yes Yes Which conclusions were supported by consistent findings from two or more good or high-quality studies? List The consistent and important conclusion across studies was the lower incidence of CAUTI with the use of intermittent catheterization. ARE THE CONSLUSIONS CREDIBLE? Clinical Significance All Some No Yes No Not Clear 19 *Across studies, is the size of the treatment or the strength of the association found or the meaningfulness of qualitative findings strong enough to make a difference in patient outcomes or experiences of care? Are the conclusions relevant to the care the nurse gives? Yes Yes All ARE THE CONCLUSIONS CLINICALLY SIGNIFICANT? Yes Applicability Yes Does the SR address a problem, situation, or decision we are addressing in our setting? Are the patients in the studies or a subgroup of patients in the studies similar to those we see? Yes Some No Yes What changes, additions, training or purchases would be needed to implement and sustain a clinical protocol based on these conclusions? Specify No changes, additions, training or purchases are required. The recommendations can be used within the existing framework of resources. Yes Is what we will have to do to implement the new protocol realistically achievable by us (resources, capability, commitment)? No Not Clear Yes How will we know if our patients are benefiting from our new protocol? Specify By evaluating the outcomes. All ARE THESE CONCLUSIONS APPLICABLE TO OUR SETTING? SHOULD WE PROCEED TO DESIGN A PROTOCO INCORPORATING THESE CONCLUSIONS? Some No Yes Yes Comments The systematic review provides excellent practice change recommendations for the EBP project. 20 APPENDIX F Appraisal Guide: Findings of a Quantitative Study APA Formatted Citation: (4 pts.) Menegueti, M. G., Ciol, M. A., Bellissimo-Rodrigues, F., Auxiliadora-Martins, M., Gaspar, G. G., Canini, S., Basile-Filho, A., & Laus, A. M. (2019). Long-term prevention of catheterassociated urinary tract infections among critically ill patients through the implementation of an educational program and a daily checklist for maintenance of indwelling urinary catheters: A quasi-experimental study. Medicine, 98(8), e14417. https://doi.org/10.1097/MD.0000000000014417 Synopsis (16 pts.) 1. What was the purpose of the study (research questions, purposes, and hypotheses)? The purpose of the study by Menegueti et al. (2019) was the evaluation of the impact of implementation of health care providers educational program as well a daily checklist for the use of indwelling catheters in the patients having critical illnesses in reducing the incidence of CAUTIs. 2. How was the sample obtained? The researchers did not do sampling. Instead, they used a twelve years period for their intervention. 3 What inclusion or exclusion criteria were used? The researchers did not specify the use of a specific inclusion or exclusion criteria for their research. 4 Who from the sample actually participated or contributed data (demographic or clinical profile and dropout rate)? The research was undertaken by the researchers themselves. 5 What methods were used to collect data (e.g., sequence, timing, types of data, and measures)? Data collection was undertaken by the researchers personally after applying the protocol designed for the researchers. 21 6 Was an intervention tested? Yes, the study comprised testing of an intervention. A How was the sample size determined? The researchers did not use a sample, and data collection was time-based instead. C. Were patients randomly assigned to treatment groups? Randomization was not undertaken by the researchers. 7 What are the main findings of the study? (10 pts.) The key finding of the research was that healthcare service providers’ education as well as daily evaluation of indwelling urinary catheter indications had extreme effectiveness in reducing the rates of catheter utilization as well as the incidence density of CAUTI. Credibility (14 pts.) Yes Is the study published in a source that required peer review? Yes *Did the data obtained and the analysis conducted answer the research question? Were the measuring instruments reliable and valid? *Were important extraneous variables and bias controlled? *If an intervention was tested, answer the following five questions: Were participants randomly assigned to groups and were the two groups similar at the start (before the intervention)? Were the interventions well defined and consistently delivered? Were the groups treated equally other than the difference in interventions? If no difference was found, was the sample size large enough to detect a difference if one existed? If a difference was found, are you confident it was due to the intervention? Are the findings consistent with findings from other studies? Yes Clinical Significance (6 pts.) Not Clear Yes Yes No Yes Yes Yes Yes All ARE THE FINDINGS CREDIBLE? No Yes Some No 22 8 Note any difference in means, r2s, or measures of clinical effects (ABI, NNT, RR, OR) Answer Here: NNT Yes *Is the target population clearly described? *Is the frequency, association, or treatment effect impressive enough for you to be confident that the finding would make a clinical difference if used as the basis for care? ARE THE FINDINGS CLINICALLY SIGNIFICANT? *= No Not Clear Some No Yes Yes All Yes Important criteria Comments The article provides good quality evidence supporting the reduction of CAUTIs with an educational intervention. Name: Description: ...
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