Reflection Clinical Incident Hiv
ABTRACT Central Venous Catheter Blood stream infections (CVCBSIs) is a major cause of morbidity and mortality in patients with end- stage renal disease treated with chronic haemodialysis (Jaber 2005). The purpose of this review is to determine whether the use of Biopatch on the exit site of central venous catheter (CVC) can help prevent infection. Before any research was undertaken, a focused question was formulated and a search strategy was then developed to compare the available evidence. A PICO (Sackett et al 1997) was undertaken using the terms Central Venous Catheter, Chlorhexidine, Biopatch and Infection.
A Facet analysis (Ranganathan 1967, cited by Spiteri 1998) was performed and a literature search was conducted using four electronic databases. This databases searches, contains both nursing and medical research and reviews. The databases used were Medline (1982-2011), CINAHL (1996-2011), Embase (1982-2011) and BNI (1982-2011) Mckibbon and Mark (1998) states that CINAHL and Medline databases are the most appropriate methodological to identify studies that report high quality research which can be used for clinical application.
Most of the search result, produced articles that were Control Randomised Trails (RCT). Torgerson and Torgerson (2008), states that RCT is the gold standard for research method and for addressing the what? question in ‘evidence-informed’ policy making and practice. The literature search in CINAHL generated 145 article and limited to 2 articles which did not answer the question directly, however before the limits were applied two articles were found to relate to the question but one article answer the question and was a crossover intervention trail.
The searches in BNI yielded 14 results and were limited to 1 article which did not relate to the question. Further searches in Medline and Embase, produced 19 and 21 results consecutively and none of this search answered the question. BACKGROUND The purpose of this research is to analysed published researched article on the effectiveness of Biopatch for the prevention of central venous catheter.
Working in an area where CVC is being used, prompted the need to look for the best evidence available for the prevention of CVC line infection. There has been a steady rise of CVC infection in the past months and this has raised concern for both patients and staffs, as some of those patients affected had to have their lines removed, and even ITU admissions. In view of this problem, the need to look for preventive method prompted the question of the efficacy of Biopatch for the prevention of CVC.
The life line of haemodialysis (HDX) patients, remain their vascular access. People with end stage renal disease (ESRD), requires a reliable access for their circulatory system to receive life sustaining HDX. The ideal access would be long lasting, free of complication and permits adequate flow rates to deliver effective treatments (Schwab 1997). 25% of hospital admissions for HDX patients are for access problems and access failure is a major cause of morbidity (Levy et al 2005).
Central Venous Catheter (CVC) is an important aspect in HDX vascular access with 46% to 70% of patients commencing HDX through CVC; however it is a known risk factor for staphylococcus aureus infection and bacteraemia, ( sattler et al). Catheter related bacteraemia (CRB) include exit site infection, tunnel line infection and bacteraemia. CRB are the most common and important infection associated with CVC use and may be cause by a wide variety of gram positive and gram negative organism (Jaber 2005).
There has been several preventive measures introduced to try and reduce the rate of CRB at the catheter insertion site or lines, this include the use of prophylactic topical antimicrobial ointments at the catheter exit site, the use of prophylactic catheter locking solution for prevention of CRB, strategies for management of the catheter and the use of vascular access managers and quality initiative programmes and also a dressing consisting of a biopolymer composite foam with antimicrobial agents are also being used to prevent infections.
For an effective databases search, a clear question must be formulated. Craig and Smyth (2007) states that a carefully formulated question maximises the likelihood that relevant, high quality evidence is identified and incorporated appropriately into decision making process. Formulating question is a fundamental skill for evidence base practitioner and this help to focus search learning time on evidence that is highly relevance to patients needs (Cullum et al (2008). Sackett et al (1997) cited in Craig and Smyth (2007)devise a framework known as PICO for making question to be more focused.
By structuring a question, the answer may be found more efficiently. The PICO divide the question into four key parts which are then the focused of the targeted literature search. According to Cullum et al (2008), the four key parts are P- population or problem, population is the client group or clinical condition or problem, I- intervention is the aspect of health care of interest or a action plan, C- counter intervention, the counter intervention involves choosing between the alternative cause of action or no action and O – outcome, is the result that is hope to achieve.
A PICO format helps with the term that can be use to begin a search for answers, it also helps to narrow down and refine the question to obtain relevant answers and outcome. See the table below. Table 1: PICO POPULATION| INTERVENTION| COUNTER INTERVENTION| OUTCOME| Central venous catheter| Chlorhexidine| None| Infection prevention| By putting each part of the question into the appropriate column, eases the task of developing a searchable question.
Devising a focused question can save a great deal of searching time with the key words of the question becoming the key term for the search. Nursing research aspire to improve the quality of care given to patients which provide nurses the opportunity to ask question about their practice and look for ways to improve them and to ensure that it is achieved and also based on evidence. This forms the background to which the focused clinical question arose “Does chlorhexidine sponge dressing (Biopatch) prevent exit site infection in CVC for patient undergoing HDX? The paper chosen answered the question and was a crossover intervention trail as reference below : Camins et al (2010) A cross over intervention trail evaluating the efficacy of a chlorhexidine- impregnated sponge in reducing catheter- related bloodstream infections among patients undergoing haemodialysis. This paper is presented as appendix 1. METHOD Clinical evidence can be acquired from numerous areas, such as text books, bibliographic data, course article and even colleague. Greenhalgh (2006) suggested that providing evidence from systematic review of existing evidence is one contribution towards achieving clinical effectiveness.
The main aim of searching is to find good quality valid evidence to support clinical decision making. Subsequently a search strategy was developed to identify appropriate literature. Any terms that could be used as alternatives to the key term were identified. This structured identification of alternatives search term is called Facet analysis (Ranganathan 1967, cited in Spiteri 1998). Facet analysis consist of the use of specific alternative spelling, abbreviations, plurals, word specific therapies, in relation to PICO word to help in analysing the search (Sackett et al 1998).
The Facet analysis was translated into a search strategy by using three key index terms as heading for each of the three facets. Synonyms were added and truncations, wild card and Boolean Operators used, were necessary. Search engine uses two methods to identify information, the first is by searching the word entered as index term and the second is by free text term which has been prepared by the compliers of the databases (Gillespie and Gillespie 2003). Another search tool used was truncations and wild cards.
The use of truncation during search helps to prevent time wasting by searching for different variation of the word and wildcard gives room to identify alternative spelling of the same word easily Craig and Smyth (2007). Truncation is represented by ($) in Ovid while wildcard is represented by (? ) and is used within or the end of a search term to substitute for one or no character An example of facet analysis is shown on the table below. Table: two POPULATION| INTERVENTION| COUNTER INTERVENTION| OUTCOME| Central venous catheter| Biopatch| None| Infection Prevention|
FACET ANALYSIS INDEX TERMS| INDEX TERMS| INDEX TERMS| INDEX TERMS| Central venous catheter| Chlorhexidine/ Biopatch| None| Infection Prevention| FREE TEXT TERM| FREE TEXT TERM| FREE TEXT TERM| FREE TEXT TERM| Central venous cathe$| Chlorhe$| None| Infectio$| Central lines| Chloraprep| | Infect| Central line$| Antimicrobial dressing| | Exit site infection| Haemodialysis lines| Antiseptic dressing| | Cat? eter related infection| CVC| Antisep$| | | Intravascular cathete$| | | Catheter related bacteremia| Vascular access| | | Bactere| Intravasc$| | | |
In health care the National Library of Medicine (NLM) has developed the Medical Subject Heading (MeSH) list which, specify terms to be used by the indexer compiling entries for Medline database. These index terms are arranged in a tree view with the specific term below more general ones. By using the MeSH system, the computer searches for relationships or connections on the basis of the initial search strategy (Gilbride2004). The literature database searches were carried out in CINAHL, MEDLINE, EMBASE and BNI as this gave wider and in-depth coverage of each element of the topic.
CINAHL and Medline databases are the most appropriate methodology to identify studies that report high quality research which can be used for clinical applications (Marks 1998). CINAHL (cumulative index to nursing and allied health literature) data base covers nursing and health science, and related discipline from 1982 to present (Greenhalgh, 2001). The MeSH was used when searching the key terms by checking the “Map to Subject Heading” checkbox on the databases main page.
This produce the Mapping display page and a list of subject headings including the key search term and various other terms based around it. By clicking on the key terms, example central venous catheter, “include Subheading” and “Explode. ” The included Subject Heading option gives a choice of either adding subheading to the subject heading or making the subject the main focus of the article (Harris, 2000). Exploding the MeSH heading incorporates all the more specific MeSH heading shown in the tree search. This process was repeated for each of the 3 key search terms.
Next a free text search of each facet was perform by un-checking the Map to Subject Heading checkbox. The free text search was necessary because according to Gillespie and Gillespie (2003), “one cannot rely solely on the accuracy of indexing, or there may not be an index term that specifically describes the concept of interest”. When this was completed, the combined searches with Boolean operator “OR” was selected, combining the terms within the same concept together and facilitating retrieval of citations containing any of the previous search term.
This was carried out for each of the 3 key terms and their facets. Boolean refers to the 19th century British mathematician George Boole who in 1847 invented “linguistic algebra”, a mathematical logic that represent relationship between entities and ideas (Harris 2000). The results of each 3 search elements combined using Boolean operator “OR” were finally combine with the operator “AND” which combined the different concepts together resulting in retrieval of citations containing all of the three core search elements ( Levy 2004).
The resulting list of the four data base search articles was limited to English language, human, randomised control trail and research paper thereby eliminating less relevant result. Medline is produced by United state National Library of medicine, Medline covers the international literature on biomedicine, allied health and Biological and physical sciences (Gray 1997). Embase focuses on pharmacology but include other biomedical specialities. It also contains information from 1974 to date and has a European bias.
British Nursing Index, (BNI) produced in the UK, contains information from 1994 to date. The search history from CINAHL, Embase, Medline and BNI databases are shown in appendices 2, 3, 4 and 5. FINDINGS OF THE REVIEW The Camis et al (2010) paper was produced by CINAHL, Medline and Embase searches and is a Crossover Intervention Trial. Cross-over studies or crossover trials are a type of randomised control trial. Cross-over studies are “studies comparing two or more treatments or interventions in which the subjects or patients, upon completion of the course of one treatment, re switched to another (Senn, 2002). In the case of two treatments, A and B, half the subjects are randomly allocated to receive these in the order A, B and half to receive them in the order B, A. A criticism of this design is that effects of the first treatment may carry over into the period when the second is given. In this study, 121 were enrolled, 2 withdrew and 119 were analysed. This particular study was chosen because of the larger sample size, as sampling error- the gap between a sample’s representativeness and the size of the sample increases (Thompson, 1999).
However a randomised control trial show that the use of chlorhexidine-impregnated dressing with tunnelled central venous catheters resulted in fewer documented exit site infection. There has been no randomised control trial study on HDX patients. The Embase search produced the largest no of citation but did not answer the research question, in Medline, 19 citations was found, 2 were randomised control trials and 1 was relevant to the question but not answer the question. BNI found 1 citation and was not relevant to the question.
However CINAHL found 145 citations and 1 answered the research question further limits were applied and this gave 2 citations which did not answer the question directly. Table three: TABLE OF FINDINGS Databases| Citations| Type of study| Relevant to question| Study population| CINAHL| 2| RCT : 2| 1| Central venous catheter| MEDLINE| 19| RCT :12| 1| Central venous catheter. | EMBASE| 21| RCT: 12| 2| Central venous catheter. | BNI| 1| RCT : O| 0| Central venous catheter. | CRITICAL APPRAISAL OF RESAERCH PAPER
O’Rourke (2005)cited in Craig and Smyth (2007) defined critical appraisal as a discipline for increasing the effectiveness of one’s reading by encouraging systematic assessment of reports of research evidence to see which ones can best answer clinical problems and inform best practice. According to Burns and Grove (1993), critical appraisal is often related to critical thinking which requires carefully developed intellectual question. Craig and Smyth (2002) states that critical appraising allows us to make sense of research evidence and thus begins to close the gap between researchers and practice.
Finally Chambers (1998) also states that critical appraisal is the assessment and interpretation of evidence by considering its systematic reviews, relevance validity and results for specific situations. In this critical appraisal, the critical appraisal skills checklist (CASP) 10 question to help make sense of randomised controlled trials by Guyatt et al (1993) was used to appraise the paper. Appendix 7 CASP is a multidisciplinary programme aimed at all those who make health care decision and all those who seek to influence the decision making process.
It help people develop skills in finding and critically appraising evidence about the effectiveness in order to promote the delivery of evidence- base health care ( Public Health Resource Unit 2006). The purpose of this study was, to determined whether the use of Chlorhexidine sponge dressing (Biopatch prevent exit site infection in central venous catheter? This question was focused enquiring the effect an intervention (Biopatch) would have on the outcome (Infection) and the population studied was 121 patients who underwent HDX through tunnelled central venous catheters. This study was not a randomised control trial.
RCT is the strongest design for questions of whether health care interventions are beneficial (Cullum et al 2008). This groups have been formed through random allocation or similar methods, this ensure that allocation bias is eliminated at baseline. This research paper was a Crossover intervention trial as stated by Senn (2002) that Cross-over studies or crossover trials are a type of randomised control trial. Cross-over studies are “studies comparing two or more treatments or interventions in which the subjects or patients, upon completion of the course of one treatment, are switched to another.
This trial was conducted in a 2 HDX centres and participates were allocated into group A which were the intervention group centre 1 and B group who where in the control group centre 2. The participants were group in the centre they dialysed in and had the same nurse to patient ratio and shared the same infection prevention specialist. The intervention was started in group A whilst group B continued with the same old routine for six months and then it was switch over where group B became the intervention group and group A control group.
The participants and staff were not blinded to the study and every patient who had a tunnel central venous catheter receives the intervention. At the beginning of the trial, there were 121 patients enrolled for the study and 2 patients withdrew from the study as they develop dermatitis after 2 sessions and 119 remain on the study. All the remaining participants were followed up and the outcome was analysed by the group they were originally allocated. A 2 sided P-value of less than or equal to . 05 was considered to denote statistical significance.
P- value is the probability the difference between the group has risen by chance (Peat et al 2008) In research this is used to indicate the likelihood that a result has occurred by chance, rather than because there is a relationship between variables. The result in this research was presented in a table and narrative form and reports that there were 37 catheter related blood stream infections (CRBSIs) during the intervention period (incidence, 6. 3 CRBISs per 1,000 dialysis session, and 30 CRBSIs during the control period (incidence, 5. 2 CRBSIs per 1000 dialysis session.
Relative risk (RR) 1. 22 (95% confidence interval (CI), 0. 75-1. 97) P= 46. 2 patients less than 2% were discontinued due to adverse effect. The result of the studies did not show significant reduction in CRBSIs. The result shows that there was not a significant reduction in the incident of CRBSIs in the group. The difference between the two centres was the frequency of dressing changes 54% vs. 39%: P=. 1 and more patients with substance abuse 9% vs. 2%: P=. 1. This was a significant risk factor for development of CRBSIs on bivariate analysis. Two variables have a P- value of less than 1.
Confidence interval, are a function of the sample size and out-come frequency, the smaller the sample size, the wider the confidence interval (Torgerson and Torgerson 2008). In this study the confidence interval was 95%. Although there is a plan to implement this, product at my area of work, these research paper has not shown any significant evidence to show the effectiveness of Biopatch for the prevention of CRBSIs although the patient and the relative might be interested in the product, a RCT needs to be done before any implementation is done. IMPLEMENTATION: SITUATIONAL ANALYSIS.
Making any changes in clinical practice is a very challenging and complex matter. In finding evidence that Biopatch may not be helpful in reducing the incidence of CRBSIs, a challenge exit in actually implementing the practice. Clinical research helps to move away from the tradition approaches whilst increasing consistency of care as well as the understanding of treatment option (Thomas 1999). Given the complexity of behaviour change and the multiple factors that can influence it in positive and negative ways, there is a growing recognition that implementation efforts should be guided by conceptual models or framework (McDonald et at 2004)
Grol and Wensing (2004) states that “one of the most consistent finding in health services research is the gap between best practice as (determined by scientific research) and actual clinical care”. They also affirmed the studies in United States and Netherland, suggest that 30%-40% of patients do not receive care according to current scientific evidence. To overcome obstacle and aid implementation of change, Grols 5 steps model of change (1997) was design. This design appears to be the right tool to use as a guide to implementing Biopatch dressings.
These 5 steps are as follows, to develop a concrete proposal for changing clinical practice. This should involve drawing up a proposal and involving the multidisciplinary team members, to discuss the proposal. Identify obstacle to change, this will involve the process of making sure all the challenges that will prevent change to be implemented are identified as proposed by Hayes (2002). The third model was to link intervention to obstacle in clinical practice. Grol (1997) says that knowing the target group well is crucial, as is the understanding their needs and problem with changing.
The obstacle to change can be address by education session and meeting in collaborative approach. Developing a plan, a key component of the plan will be staff and patients education about the product. The use of this product should be started in a small minority of the patients with a developed care plan in place to monitor any changes. Carry out the plan, the use of Biopatch will be evaluated and continuous audit will be carried out monthly and the result will be discussed with other multidisciplinary team.
Carrying out an effective plan and evaluation of progress by performance of audit and survey as has been established by Greenhalgh (2006). CONCLUSION In conclusion, this research review has shown that Biopatch was not effective in the prevention of CRBSIs, however other studies by Timsit et al (2009) has demonstrated that Biopatch was effective in reduction of CRBSIs in critically ill patients and also another trial carried out on neutropenic patients also show significant reduction in CRBSIs, although there has been no research done, before this on patient undergoing HDX.
The method used to find evidence include a focused question, planning the literature search using PICO and Facet analysis, using electronic databases for literature searches, appraising the evidence and developing an implementation strategy. Grol’s 5step model was found to be helpful and practical tool in planning the implementation. The method of search provided a good structure around to base clinical exploration or enquiry and has improved my knowledge in searching the databases for clinical evidence. REFERENCES Timsit JF, Schwebel C, Bouadma L. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter related infections in critically ill adults: a randomised controlled trial. JAMA 2009, 301: 1231-1241. Carmis BC, MD, MSCR,. Richmond M, RN, MHS, CIC,. Dyer KL, MPH. Zimmerman HN, MPH,. Coyne DW, MD. Rothstein M, MD. Fraser VJ, MD. ; Infection Control and Hospital Epidemiology, Vol. 31, No 11 (November 2010), pp. 1118-1123. Levy J, Morgan J, Brown E. 2005) A practical guide todialysis and how to manage end stage renal failure. Oxford handbook of dialysis (2nd edn) New York: Oxford University Press.
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