Research Critiques And PICOT Statement Final Draft1

Table of Contents

Research Critiques
Research Critiques

Prepare this assignment as a 1,500-1,750 word paper using the instructor feedback from the Topic 1, 2, and 3 assignments and the guidelines below. 

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PICOT Statement 

Revise the PICOT statement you wrote in the Topic 1 assignment.

Research Critiques

In the Topic 2 and Topic 3 assignments you completed a qualitative and quantitative research critique. Use the feedback you received from your instructor on these assignments to finalize the critical analysis of the study by making appropriate revisions.

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The completed analysis should connect to your identified practice problem of interest that is the basis for your PICOT statement.

Refer to “Research Critique Guidelines.” Questions under each heading should be addressed as a narrative in the structure of a formal paper.

Proposed Evidence-Based Practice Change

Research Critiques

Discuss the link between the PICOT statement, the research articles, and the nursing practice problem you identified. Include relevant details and supporting explanation and use that information to propose evidence-based practice changes.

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

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.


Running Head: Decreasing CLABSI Infections 1

PICOT Statement and Literature Search



Research Critiques

· Ensure that you are only using third person language for APA format.

· The only change that needs to take place is for you to ensure you are in the proper order. It will sound weird, but it is truly the best format. PICOT.

In researching articles for this paper, I turned to both Qualitative and Quantitative peer reviewed articles. I also performed a lot of independent research, so I could knowledgably select the best articles for this research. According to the United States Centers for Disease Control and the Society for Healthcare Epidemiology of America and the Disease Society of America (SHEA-IDSA) report, the third most common Healthcare Associated Infection are Central Line Associated Blood Stream Infections or CLABSI.

Hospital-acquired infections (HAIs) affect 1.7 million patients annually and result in 99,000 deaths each year (US Department of Health and Human Services, 2010). CLABSIs are a subset of bloodstream infections, and while Klevens et al (2007) estimated that the deaths caused by or associated with a HAI were 98,987 per year, one-third of these were secondary to CLABSIs resulting in a 12.3% mortality rate (U.S. Department of Health and Human Services, 2009). CLABSIs result in prolonged stays in the intensive care unit (ICU) with medical costs averaging an additional $11,971 per patient (Warren et al., 2006). The overall effect of CLABSIs results in annual expenditures of 2.3 million dollars in U.S. hospitals (Blot et al., 2005). However, with preventive measures, these costs could be greatly reduced and perhaps eliminated.

CLABSI – Centers for Disease Control and Prevention (CDC) definition: CLABSI is a surveillance definition used by the CDC and defined as recovery of a pathogen from a blood culture (a single blood culture for organism not commonly present on the skin, and two or more blood cultures for organism commonly present on the skin) in a patient who had central line at the time of infection or within 48 hours before development of infection. The infection cannot be related to any other infection the patient might have and must not have been present or incubating when the patient was admitted to the facility.

The research on CLABSI indicates the most common pathogens are Staphylococcus Aureus, Enterococci, and Candida. According to further CDC guidelines, LCBIs are divided into LCBI 1, LCBI 2, and LCBI 3 (in patients < 1 year of age), An LCBI 1 is defined as a patient with a recognized pathogen cultured from one or more blood cultures, and these cultured bacteria is not related to an infection at any other site. This confirms that the bloodstream infection is not related to another source of infection and is therefore determined to be caused by the central line. LCBI 2 requires that the patient have either fever (>38°C), chills, or hypotension, alongside positive blood lab results (cultures) that are not related to infection at another site. Finally, bacteria must be cultured from two or more blood tests drawn within a 24-hr period. LCBI 2 allows for diagnosis of a CLABSI when blood cultures reveal a microorganism that is not strictly pathogenic in nature (CDC, 2016).

PICO Parts and PICO Question

Research Critiques

· P: Population/patient – Patients developing central line associated bloodstream infections (CLABSI).

· I: Intervention/indicator – Handwashing, Antimicrobial catheters and chlorhexidine baths to decrease CLABS.

· C: Comparison/control – Regular bath with soap and water

· O: Outcome – Decreased rates of CLABSI infections in patients with Central vein catheters.

Research Question: In hospitalized patients with central access devices (P), what is the effect of daily chlorohexidine baths (I) on decreasing incidence of CLABSI infections (O) compared with daily baths with soap and water (C) within a hospital stay (T)?

Six (6) Peer Reviewed Research Articles

Quantitative with Abstract-

1) Curlej, MH. 2016. One Rural Hospital’s Experience Implementing the Society for Healthcare Epidemiology of America Guidelines to Decrease Central Line Infections. Journal of Trauma Nursing. 23 (5):290-297.


In an effort to take advantage of the Highmark Quality Blue Initiative (N. D. Bastian, H. Kang, H. B. Nembhard, A. Bloschichak, P. M. Griffin, 2016) requiring information from hospitals detailing their central line-associated blood stream infections (CLABSIs) surveillance system, quality improvement program, and statistics regarding the CLABSI events, this institution investigated the latest evidence-based recommendations to reduce CLABSIs. Recognizing the baseline rate of 2.4 CLABSIs per 1,000 central line days and its effect on patient outcomes and medical costs, this hospital made a commitment to improve their CLABSI outcomes. As a result, the facility adopted the Society for Healthcare Epidemiologyof America (SHEA) guidelines. The purpose of this article is to review the CLABSI rates and examine the prevention strategies following implementation of the SHEA guidelines. A quantitative, descriptive retrospective program evaluation examined the hospital’s pre- and post-SHEA implementation methods of decreasing CLABSIs and the subsequent CLABSI rates over 3 time periods. Any patient with a CLABSI infection admitted to this hospital July 2007 to June 2010 (N = 78). CLABSI rates decreased from 1.9 to 1.3 over the study period. Compliance with specific SHEA guidelines was evaluated and measures were put into place to increase compliance where necessary. CLABSI rates at this facility remain below the baseline of 2.4 for calendar year 2013 (0.79), 2014 (0.07), and 2015 (0.33).

2) Bonne, S., Mazuski, J. E., Sona, C., Schallom, M., Boyle, W., Buchman, T. G., … Schuerer, D. J. E. (2015). Effectiveness of Minocycline and Rifampin vs Chlorhexidine and Silver Sulfadiazine-Impregnated Central Venous Catheters in Preventing Central Line-Associated Bloodstream Infection in a High-Volume Academic Intensive Care Unit: A Before and after Trial. Journal of the American College of Surgeons221(3), 739–747.


Background Use of chlorhexidine and silver sulfadiazine-impregnated (CSS) central venous catheters (CVCs) has not been shown to decrease the catheter-related bloodstream infection rate in an ICU. The purpose of this study was to determine if use of minocycline and rifampin-impregnated (MR) CVCs would decrease central line-associated bloodstream infection (CLABSI) rates compared with those observed with use of CSS-impregnated CVCs. Study Design A total of 7,181 patients were admitted to a 24-bed university hospital surgical ICU: 2,551 between March 2004 and August 2005 (period 1) and 4,630 between April 2006 and July 2008 (period 2). All patients requiring CVC placement in period 1 had a CSS catheter inserted, and in period 2 all patients had MR CVCs placed. Results Twenty-two CLABSIs occurred during 7,732 catheter days (2.7 per 1,000 catheter days) in the 18-month period when CSS lines were used. After the introduction of MR CVCs, 21 catheter-related bloodstream infections occurred during 15,722 catheter days (1.4 per 1,000 catheter days). This represents a significant (p < 0.05) decrease in the CLABSI rate after introduction of MR CVCs. Mean length of time to infection developing after catheterization (8.6 days for CSS vs 6.1 days for MR) was also different (p = 0.04). The presence of MR did not alter the microbiologic profile of catheter-related infections, and it did not increase the incidence of resistant organisms. Conclusions the CLABSI rate decreased more with the use of MR CVCs compared with CSS CVCs in an ICU where the CLABSI rate was already low. The types of organisms causing infection were similar. With continued use of MR-impregnated CVCs in our ICU in the subsequent 5 years, we have seen sustained low rates of CLABSIs. [ABSTRACT FROM AUTHOR]

3) Benjamin Woodward, & Reba Umberger. (2016). Review of Best Practices for CLABSI Prevention and the Impact of Recent Legislation on CLABSI Reporting. SAGE Open, Vol 6, Iss 4 (2016), (4).


Central line-associated bloodstream infections (CLABSI) are a very common source of healthcare-associated infection (HAI). Incidence of CLABSI has been significantly reduced through the efforts of nurses, healthcare providers, and infection preventionists. Extrinsic factors such as recently enacted legislation and mandatory reporting have not been closely examined in relation to changes in rates of HAI. The following review will examine evidence-based practices related to CLABSI and how they are reported, as well as how the Affordable Care Act, mandatory reporting, and pay-for-performance programs have affected these best practices related to CLABSI prevention. There is a disconnect in the methods and guidelines for reporting CLABSI between these programs, specifically among local monitoring agencies and the various federal oversight organizations. Future research will focus on addressing the gap in what defines a CLABSI and whether or not these programs to incentivize hospital to reduce CLABSI rates are effective.

Qualitative with Abstract-

4) McAlearney, A. S., & Hefner, J. L. (2014). Original article: Facilitating central line–associated bloodstream infection prevention: A qualitative study comparing perspectives of infection control professionals and frontline staff. AJIC: American Journal of Infection Control42(Supplement), S216–S222.


Background Infection control professionals (ICPs) play a critical role in implementing and managing healthcare-associated infection reduction interventions, whereas frontline staff are responsible for delivering direct and ongoing patient care. The objective of our study was to determine if ICPs and frontline staff have different perspectives about the facilitators and challenges of central line-associated bloodstream infection (CLABSI) prevention program success.

Methods We conducted key informant interviews at 8 hospitals that participated in the Agency for Healthcare Research and Quality CLABSI prevention initiative called “On the CUSP: Stop BSI.” We analyzed interview data from 50 frontline nurses and 26 ICPs to identify common themes related to program facilitators and challenges.

 Results We identified 4 facilitators of CLABSI program success: education, leadership, data, and consistency. We also identified 3 common challenges: lack of resources, competing priorities, and physician resistance. However, the perspective of ICPs and frontline nurses differed. Whereas ICPs tended to focus on general descriptions, frontline staff noted program specifics and often discussed concrete examples.

 Conclusions Our results suggest that ICPs need to take into account the perspectives of staff nurses when implementing infection control and broader quality improvement initiatives. Further, the deliberate inclusion of frontline staff in the implementation of these programs may be critical to program success.

5) Donskey, C. J., & Deshpande, A. (2016). Effect of chlorhexidine bathing in preventing infections and reducing skin burden and environmental contamination: A review of the literature. American Journal of Infection Control, 44, e17–e21.


Chlorhexidine bathing is effective in reducing levels of pathogens on skin. In this review, we examine the evidence that chlorhexidine bathing can prevent colonization and infection with health care-associated pathogens and reduce dissemination to the environment and the hands of personnel. The importance of education and monitoring of compliance with bathing procedures is emphasized in order to optimize chlorhexidine bathing in clinical practice.

6) Scheck McAlearney, A., Hefner, J., Robbins, J., Harrison, M., & Garman, A. (2015). Preventing Central Line–Associated Bloodstream Infections: A Qualitative Study of Management Practices. Infection Control & Hospital Epidemiology, 36(5), 557-563. doi:10.1017/ice.2015.27


OBJECTIVE: To identify factors that may explain hospital-level differences in outcomes of programs to prevent central line–associated bloodstream infections.

DESIGN: Extensive qualitative case study comparing higher- and lower-performing hospitals on the basis of reduction in the rate of central line–associated bloodstream infections. In-depth interviews were transcribed verbatim and analyzed to determine whether emergent themes differentiated higher- from lower-performing hospitals.

SETTING: Eight US hospitals that had participated in the federally funded On the CUSP—Stop BSI initiative.

PARTICIPANTS: One hundred ninety-four interviewees including administrative leaders, clinical leaders, professional staff, and frontline physicians and nurses.

RESULTS: A main theme that differentiated higher- from lower-performing hospitals was a distinctive framing of the goal of “getting to zero” infections. Although all sites reported this goal, at the higher-performing sites the goal was explicitly stated, widely embraced, and aggressively pursued; in contrast, at the lower-performing hospitals the goal was more of an aspiration and not embraced as part of the strategy to prevent infections. Five additional management practices were nearly exclusively present in the higher-performing hospitals: (1) top-level commitment, (2) physician-nurse alignment, (3) systematic education, (4) meaningful use of data, and (5) rewards and recognition. We present these strategies for prevention of healthcare-associated infection as a management “bundle” with corresponding suggestions for implementation.

CONCLUSIONS: Some of the variance associated with CLABSI prevention program outcomes may relate to specific management practices. Adding a management practice bundle may provide critical guidance to physicians, clinical managers, and hospital leaders as they work to prevent healthcare-associated infections. Infect Control Hosp Epidemiol 2015;00(0): 1–7.



Chlorhexidine Bathing

Research Ethics and Evaluating Qualitative Research


· No contractions in APA writing.

· You discuss what the authors “should” do, but what did they actually do?

· You will need to increase your critique statements about how well the authors do at presenting the information in each section. Were they adequate or is there information missing? What could they have done better?

Article Summary

The article “Effect of chlorhexidine bathing in preventing infections and reducing skin burden and environmental contamination: A review of the literature” by Curtis and Abhishek focuses on the effects of chlorhexidine bathing on the patient’s skin. According to Donskey & Deshpande (2016), Chlorhexidine is described as a cat ionic bisbiguanide antiseptic which alters the integrity of the microbial membrane. Potent spermicidal activity in chlorhexidine is induced under altered chemical and physical conditions such as altered PH, elevated temperature, and an addition of ethanol. Under the normal skin conditions, chlorhexidine doesn’t have activity against the bacterial spores. Also, chlorhexidine is used in various antiseptics, preservative, and disinfectant applications. Daily chlorhexidine bathing is associated with a decrease in VRE on the skin; it’s used as a strategy of reducing the dissemination of healthcare linked pathogens. Chlorhexidine bathing is easy to implement since it entails the substitution the standard soap-and-water bathing. Chlorhexidine bathing has a broad-spectrum activity, and it represents the horizontal infection prevention strategy which potentially reduces the dissemination of various pathogens (Donskey & Deshpande, 2016).

Additionally, daily chlorhexidine bathing has effects on colonization as well as infection with pathogens. It reduces gram-negative and gram-positive bacteria as well as Candida spy on the skin. Bacteria and Candida spy on the skin is also associated with a reduction in infection or colonization of pathogens. Chlorhexidine has beneficial effects when applied using cotton cloths with 4% or 2% chlorhexidine solution and 2% chlorhexidine-impregnate cloths (Donskey & Deshpande, 2016).

The article reviews various randomized trials on the effect of chlorhexidine bathing on infections acquired in a hospital setup. First, a non-blinded crossover trial was conducted to determine the effect of daily chlorhexidine- impregnated washcloths bathing on MDROs (multidrug-resistant organisms) acquisition as well as the frequency of hospital-acquired bloodstream infections. The experiment results indicated that hospital-acquired bloodstream infection and MDRO acquisition rates reduced by 28 percent and 23 percent respectively. The bloodstream infection reductions were associated with a decrease in infections with coagulase-negative staphylococci. The second trial was a multicenter, cluster-randomized crossover experiment which involved critically ill babies in 10 ICUs. It was established that chlorhexidine bathing significantly reduced bacteremia (Donskey & Deshpande, 2016)

The third trial is a rational cluster-randomized, cross-over research which involved adults in five ICUs in a tertiary care health center. The experiment outcome showed that there was no difference between the control group and chlorhexidine in the primary outcome which was composed of nosocomial infections, including CDI, ventilator associated pneumonia, catheter-associated urinary tract infection, and CLABSIs.

Additionally, there was no association between chlorhexidine bathing and reduction in secondary outcomes like clinical cultures yielding MDROs, blood culture contamination, and hospital-acquired bloodstream infections. The last trial is Thailand’s randomized open-label controlled trial which involved four medical ICUs. The results indicated that there is no difference in the outcomes which include length of hospital and intensive care stay, hospital-acquired infection, and colonization with MDROs. The experiment’s negative results may be attributed to the presence of gram-negative bacilli in the ICUs (Donskey & Deshpande, 2016).

Ethical Considerations

In this study, the researchers should weigh the benefits and risks to which the participants are exposed to ensuring their welfare and rights are protected. All the participants should be informed about the project’s purpose and should participate voluntarily. Permission should be sought when recording interviews; the participants should be assured that their responses will be kept confidential and that their identity will not be identified in any publication or report. All members who agree to take part in the research should sign a document which shows that they have agreed to participate voluntarily (Willett, 2015).

Additionally, the nurses should use a utilitarian approach when making decisions; they should be clear on what is a good and bad consequence. In the past, this has been defining as material gain, happiness, satisfaction of desires and knowledge. The other question that needs to be addressed is “whose good is being promoted.” Where the patient is not exposed to the risk of physical harm by not having the bath, the nurses’ justification can reflect ethical parochialism, or promotion of good institution through client conformity and maintaining good air (Willett, 2015).

Application in nursing practice

An increase in MDRO (multi-drug resistant organisms) like vancomycin-resistant Enterococcus (VRE) and Acinetobacter baumannii has limited the available number of effective antibiotics for treatment, thus increasing health care costs, patient morbidity, and mortality, and prolonging hospital stay. The concept that these infections can be prevented has led to the development of strategies as well as therapies to reduce infection rates. On such strategy is daily patient bathing with CHG (chlorhexidine gluconate). According to Donskey & Deshpande (2016), CHG has been used to control cross infections (used as a decolonization therapy). Also, due to its broad-spectrum antimicrobial effects, CHG is used to disinfect the patient’s skin for intravascular catheter insertion and surgical procedures. Chlorhexidine gluconate is used to kill fungi, bacteria, and some viruses. CHG, unlike other antiseptics, has the residual antibacterial activity that prevents secondary environmental contamination and reduces microbial colonization of the patient’s skin. Daily bathing with chlorhexidine gluconate decreases the physicians’ hand contamination, patient bacterial skin colonization, as well as environmental surface contamination. Cleaning the skin of ICU patients daily with Chlorhexidine reduces frequencies VRE (vancomycin-resistant Enterococcus) and multi-drug resistant Acinetobacter baumannii (Donskey & Deshpande, 2016).


Donskey, C. J., & Deshpande, A. (2016). Effect of chlorhexidine bathing in preventing infections and reducing skin burden and environmental contamination: a review of the literature. American journal of infection control44(5), e17-e21.

Willett, K. (2015). Evaluation of Chlorhexidine Bathing Practices in Trauma/Surgical Intensive Care Units.

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