Homework Lance
Grand Canyon University
NRS 433V
Nursing Practice Problem[MR2] and PICOT Statement
In today’s time where there are more prominent diseases such as cancer, cardiovascular, and endocrine diseases such as diabetes can lead to major health crisis, our patient population in intensive care units need a more secure and longer lasting intravenous line. These lines prove useful when there is need for multiple intravenous medications, especially for those medications that are contraindicated with the use of a peripheral venous access such as lipids and chemotherapy agents. The use of central lines is also commonly used for long term antibiotic therapy lasting for more than a week. Central lines can be lifesaving but they can also be the cause of longer hospital stays related to infections.
Nursing Practice Problem
One of the most common but preventable hospital acquired infections is central line-associated blood stream infection (CLABSI), also known as a catheter related blood stream infection. The most common central line used in acute care in a Peri[MR3] pherally inserted central line catheter Known as PICC line. This type of line is mostly inserted by specially trained nurses. Two distinct situations that place patients at a risk of acquiring a CLABSI are at the time of insertion and hub manipulation for blood sampling, medication administration, and routine line maintenance. Nurses have the responsibility have the responsibility to implement the right interventions to prevent them. Nurses are in a unique position to prevent CLABSIs. It would not be an understatement to say that CLABSI prevention is completely an nursing responsibility.
PICOT Statement
The vast majority of patients in intensive care units tend to have central lines because of their fragile state of health and generally need intravenous access that is more stable and able to tolerate medication where peripheral access is contraindicated.
P- Adult patients in intensive care units (ICU)
I- The use of antimicrobial lock system (ALT)
C- Compare to simple wipe with alcohol prep wipes
O- Reducing CLABSI
T- While having a central [MR4] line
Qualitative Study
Background Study
Central line- associated bloodstream infection (CLABSI) is an ongoing issue in healthcare setting, causing increased mortality and billions in dollars in healthcare costs (White & Lowe, 2013). In an investigation conducted by the Centers for Disease Control and Prevention better known as the CDC in 2011, they found that CLABSI’s have a high mortality rate of 12 to 25 percent. Central line – associated infections are preventable through proper care and most importantly proper insertion technique. Other methods in the prevention and reduction of CLABSIs include specific bundles, staff education and development programs, improved culture of safety and adhering to guidelines for best insertion practices. Such practices have significantly reduced CLABSIs in the intensive care unit (ICU) settings but thousands of patients with central lines outside of ICU continue to acquire central line infections. It was estimated that 37,000 outpatient hemodialysis patients and 23,000 hospitalized patients hospitalized patients in non-ICUs developed CLABIs in 2008 and 2009 (CDC, 2011). That numbers suggested that at least 60,00 had a higher mortality rate and an increase in healthcare costs. As there are trends suggesting that CLABSIs are not only limited to ICU patients, this paper is to explore current literature or data on CLABSIs and emphasize that more investigation is needed in patients with central lines outside of the ICU setting.
Method of Study
Literature review was selected as the primary method to obtain data on current research studies involving CLABSIs. One of the first CLABSI studies included all adult patients in ICU in Michigan (White & Lowe, 2013). These ICUs implemented five evidence based practices recommended by CDC, handwashing, the use of personal protective devices during insertion of any central line catheter, sterile skin preparation with the use of chlorohexidine, avoiding femoral and sites, and removing medically unnecessary catheter devices. The data collected suggested that there was daily communication on whether the central line was a medical necessity and a checklist was set in place to make certain there was a policy compliance. Each month a record was kept on the occurrences of CLABSIs and reported each quarter. Improvements were observed within the first three months and the reported decrease was zero compared to a baseline of 2.7 per 1,000 catheter days. Well after the study, there was a 66% decline in CLABSI demonstrating that changes in daily practices can yield lasting results. Another similar study in Rhode Island that included all 23 ICUs, produced similar results when evidence based practice behaviors were applied. The study in Rhode Island steadily resulted in lower cases of CLABSIs in January until it reached to zero cases in June 2008 (White & Lowe, 2013). Studies also concluded that the largest percentage of CLABSIs occurred in peripherally inserted central catheters and non tunneled hemodialysis catheters. The study also found that the most prevalent bacteria that contributed to CLABSIs was vancomycin resistant enterococci and also the bacteria that was associated with contaminated samples. Another participating ICU location implemented central line insertion bundles and added a post insertion bundle that included nursing interventions such as, daily inspection of site, dressing change every seven days or when visibly soiled using chlorhexidine gluconate, cleaning the hubs prior to using the line and handwashing. The introduction and implementation of a post insertion bundle and the further decrease of CLABSIs supported the need for both an insertion and post insertion bundle.
Educational programs to reduce CLABSIs were also reviewed. Each educational program had a pre-and post-test to assess the educational need and the outcome of the teaching and create measurable data. These educational programs consisted of short length lectures conducted by infection control experts. Fact sheets and CLABSI rate data was shared. Another educational module based on compliance included fact sheets and posters illustrating steps to reduce CLABSI. The last educational method was using the CDC guidelines on the prevention of CLABSIs to all ICU staff. The study concluded that educational programs in place significantly reduced the CLABSI rate. The educational programs also proved increased staff compliance specially when it included proper dressing change, access and use of closed medication system, assessing for the need of a central line and prompt removal along with sharing fact sheets on CLABSIs.
Another population studied was those patients that were in non-ICU settings. Although the usage of central lines was higher in the ICU units, the overall number of patients with central lines was higher on the medical floors at 70% (White & Lowe, 2013). The larger volume of central lines found outside the ICU setting calls for further research on CLABSIs in general wards particularly pediatric and cancer patients
Result of Study
Results of the study showed decreased CLABSIs in ICU when CDC guidelines were followed and institutions were proactive and set their own policies to follow. When educational programs were available to healthcare staff, there was a notable decline in CLABSIs in the ICUs. CLABSIs contribute to an additional hospital cost of more than $36,000 per infection, extending hospital stays and raising mortality rates (White & Lowe, 2013). With cost-effective measures such as following best practice, lectured led by infection control personnel, easily visible CLABSI prevention posters and fact sheets nurses can prevent and/or reduce the incident rate of CLABSIs and save hospital money.Care bundles need to be individualized for each setting. Until further research is conducted on the general medical floors, nurses are recommended to follow the same ICU CLABSI guidelines set by their institution. Often times, central lines are maintained on the medical floors, in such cases, the staff nurses can follow the CDC guidelines for best practices.
Ethical Considerations
Confidentiality was kept throughout the study without revealing the name of the institutions in which the studies were conducted. Each study was conducted in their institution and approved by the institution’s review board.
It is evident that most of the research was conducted in ICU settings, until further investigation is done on the general floor, nurses should follow CDC guidelines in the prevention of CLABSIs. Another option for nurses is to follow their institution’s guidelines until further studies are conducted and new guidelines are in place. CLABSI guidelines should be appropriate for each hospital setting in order to achieve a higher compliance rate and reduced central line infections. Overall, there was a significant improvement in the care of patients with central lines when best nursing practice was used and policies were set in place along with staff development lectures on how to deliver safer and more efficient care.
Quantitative Study
Background of Study
In the wake of increased central-line associated bloodstream infections, much studies have been done to eradicate or decrease these costly incidents. Once a central-line catheter is believed to be infected, many physicians believed that removal of the catheter is the best option for managing an CLABSIs. However, catheter salvage could be an option especially for situations where venous access is poor and incidence of infection is high (Vassallo, Dunais& Roger, 2015). Examples of increased infection rate are catheters that used for hemodialysis, parental nutrition and those used for onco-hematology therapy. In situations where Staphylococcus aureus and fungi are present, removal of the catheter is the best treatment option. Central line associated bloodstream infections are linked to morbidity, mortality, longer hospital stays and high costs. Antimicrobial lock therapy (ALT) seems to be a promising approach for the treatment of central line associated bloodstream infections (CLABSI) (Vassallo, Dunais& Roger, 2015). The treatment is easy and requires instilling an antibiotic solution into the hub of the central venous catheter when not in use. Antimicrobial and antifungal molecules have shown increased efficacy against CLABSI alone or in combination with other antibiotics.
Method of Study
Articles from the Pummed database using the broad search term such as “central-line infection” and “lock therapy” were obtained. Case-control studies evaluating two or more drugs as ALT in central venous catheter infections were included (Vassallo, Dunais& Roger, 2015). Some experimental models and in vivo studies on humans were considered. The research was conducted in April 2014 and [MR6] updated in December 2014. Two hundred and twenty-one articles were selected.
Results of the Study
In the United States, approximately 80,000 cases of CLABSI occur among 3 million central venous catheters (Vassallo, Dunais& Roger, 2015). While, the numbers seem staggering, in recent CDC reports reveal a 58% decrease of CLABSIs in ICU from 2001 to 2009. The measured incidence trend in pathogenic-specific CLABSI in ICU began to dramatically reduce in 2006. The CLABSI ratios lies between 1.9 and 6.8 episodes per 1,000 catheter-days, with a median of 2.75. The odds ratio for in-hospital death related to CLABSI was 2.75, decreasing to 1.51.
Microorganisms found on the skin or in the catheter hub are the main cause of CLABSIs. The leading pathogen is Staphylococcus aureus and coagulase negative staphylococci (CoNS). Other microorganisms include Enterobacteriaceae, Pseudomonas and fungi. The use of aminoglycosides revealed that gentamicin lock therapy is active against S. aureus and CoNS. Also, amikacin locked for 12 hours resulted in 90% successful treatment of CLABSI (Vassallo, Dunais& Roger, 2015). Candida albicans is the most common fungal associated with CLABSIs. Although guidelines suggest removing the central venous catheter as the best treatment, there are reports of effective ALT. Lipid Amphotericin formulations, echinocandins and 25% ethanol proved to have good success rates in salvaging catheters with CLABSIs. Vancomycin lock therapy is active against gram positive bacteria such as methicillin- resistant staphylococci. Vancomycin ALT alone or in combination with an aminoglycoside agent or ethanol proved successful and avoided catheter removal. Daptomycin (DPT)is a cyclic lipopeptide antibiotic, which a rapid, concentration-dependent bactericidal activity against most clinically important gram-positive bacteria, including methicillin resistant Staphylococcus aureus (MRSA), CoNS, vancomycin resistant enterococci and penicillin resistant Streptococcus pneumoniae. DPT is a calcium dependent antibacterial agent and is being studied with Lactated Ringer’s solution for its capacity to work with free calcium ions. Ethanol lock therapy alone or in combination was effective as lock therapy against Strenotrophomonasmaltophilia. Broad spectrum antibiotics like aminoglycosides, fluoroquinolones and tigecycline and their potential for antimicrobial lock therapy is limited by the lack of studies of these molecules.
Ethical Considerations
Pa[MR7] tient privacy was maintained throughout the study and ethical principals were applied by not doing any harm to patients involved. The protection of the participants was not compromised.
Conclusion
Studies evaluating the efficacy of antimicrobial lock therapy for central line associated bloodstream infections vary according to the type of antibiotic used. The causative agent determines on the type of antimicrobial lock therapy that needs to be used. The most promising indication for treating CLABSI with ALT appears to be CoNS related infection, where systemic signs of infection are generally less severe and the introduction of molecules, such a DPT, improve the potential to cure without catheter removal (Vassallo, Dunais& Roger, 2015).
Overall, antimicrobial lock therapy proves to be effective against CLABSI. It proves to decrease morbidity, mortality and decrease costs. While more research is needed to evaluate the efficacy of other broad-spectrum antibiotics used in ALT, the already in use have decreased the CLABSI incident in ICU patients. These studies have shown that central venous catheters can be salvaged, thus reducing CLABSI re-infections.
References
Vallaso, M., Dunais, B., & Roger, P. (2015). Antimicrobial Lock Therapy in central-Line Associated Bloodstream Infections: A Systematic Review. Infection 43, no. 4: 389-398.
CINHAL Complete, EBSCOhost (accessed September 16, 2018).
Vital Signs: Central Line- Associated Blood Stream Infections- United States, 2001,2008 and 2009. (2011, March 04). Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6008a4.htm
Whited, A., & Lowe, M. J., (2013). Central Line- Associated Bloodstream Infection: Not Just an
Intensive Care Unit Problem. Clinical Journal of Oncology Nursing, 17(1), 21-24.
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[MR1]The title of you paper comes here
[MR2]Decrease the space between your header and title
[MR3]No need to capitalize
[MR4]You need to also include your developed PICOT statement
[MR5]This needs to come at the end of your paper not in the middle the purpose of a conclusion is to wrap up your paper
[MR6]This really does not give me an nice discussion of what the actual methods were
[MR7]Indent here
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