appraisal paper

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Quantitative Synopsis and Appraisal

Studentfirstname Studentlastname

College of Nursing, Resurrection University

NUR4440: Research in Nursing

Professor Carina Piccinini

February 14, 2020

( 1 )

Quantitative Appraisal and Synopsis

The purpose of this paper is to summarize and appraise a research study exploring the relationship between disinfectant cap implementation and rate of hospital associated bloodstream infections (BSI). The Centers for Disease Control and Prevention (CDC, 2019) reports that central line associated bloodstream infections (CLABSI) remain a major concern in hospital settings causing fatalities, increased length of stay, and increased costs. The CDD (2019) recommends proper maintenance of intravenous lines to reduce the risk of infection. Current research is still looking to define what proper maintenance should include, including whether disinfectant caps influence rates of infection for intravenous (IV) lines.

Summary of the Study

Merrill, Sumner, Linford, Taylor, and Macintosh (2014) conducted a quasi-experimental study to identify if disinfectant caps reduce CLABSI incidence and the relationship between nursing compliance with the caps and CLABSI rates. This study was held in a single Trauma 1 hospital with 430 beds in the United States.

The researchers obtained their sample through nonrandom convenience sampling and included all patients meeting inclusion criteria at the hospital starting January 2012. Participants needed to have a central or peripheral intravenous line, could be of any age, and need to be admitted to 13 specific hospital floors. Subjects were excluded if they were on the following floors: emergency department; labor, delivery or post-partum; ambulatory care, surgical services; and well-baby nursery. The study did not report any demographic information about participants, the number of participants, or attrition or loss to follow up.

The intervention involved applying a Curos brand disinfectant cap to all peripheral lines, central lines, and IV tubing when not in use on patients. The nurses on the involved units were trained on the use of the disinfectant caps with a 1:1 follow up. Nurses were then responsible for placing caps. Researchers observed nurses to watch for compliance issues and reported compliance to nursing departments twice a week. CLABSIs were defined as a positive blood culture drawn within 48 hours symptom onset, and CLABSI information was retrieved from medical record audits presumably, although the authors never explicitly state how they collected the data. CLABSI information was collected for 12 months prior to the intervention and during the 12 months following the intervention for comparison.

Appraisal

The CDC recommends that healthcare workers disinfect all needleless connectors for peripheral and central IVs prior to connection to reduce the risk of CLABSIs without further recommendation on the type or length of disinfections. The authors note other studies have tested disinfecting caps and suggest that additional research can help confirm those results.

The sampling method for this study included all patients with peripheral or central lines, with data collection for CLABSIs both pre- and post-intervention. Given that a control versus experimental group design and sampling may have made it difficult to control for extraneous variables due to variations in patient conditions and the number of connector access attempts, the sampling method was appropriate. Inclusion and exclusion criteria were included in the report. The exclusion criteria eliminated areas with rapid turnover in patients who would not have IV lines placed at all or for very long. This adequately ensured that the compliance rate would not be skewed by these care areas.

Although the measurement of CLABSIs using medical records has inherent bias, it was the only feasible way to obtain the data. On the other hand, the researchers did not explain fully how they observed if the disinfectant caps were on all patients or how compliance was counted. In fact, the authors state that nurses complained that ports high on IV tubing were being counted against them as noncompliance when there is no research indicating whether caps should be placed on those ports. Therefore, measurement bias for cap application and compliance could be quite high for this study.

The authors of this study concluded that the use of disinfectant caps decreased the rate of CLABSIs after implementation. According to the results, the mean rate of CLABSIs was 1.5 for 12 months before implementation and 0.88 for 12 months after implementation, and the authors concluded that the use of disinfectant caps decreased the rate of CLABSIs. Of note, the change in the mean rate was not tested for statistical significance. However, using a different statistical method, the authors found that the incident rate ratio after implementation was statistically significant, causing a 40% drop in bloodstream infections.

The authors acknowledged the limitation that the facility was providing education to nurses on preventing bloodstream infections outside the study interventions, which may have provided more favorable study results. While the explanation of this limitation was sufficient, it presents the possibility of considerable bias in the study.

Conclusion

This study indicates that disinfectant caps could impact rates of bloodstream infections. However, given the fact that certain aspects of the study may have influenced results in favor of disinfectant caps, more research with fewer extraneous variables interfering with results needs to be reported. The implications of this research, however, are that nurses should be compliant with existing facility protocols for intravenous line maintenance regardless of the method used and advocate for research and quality improvement studies to identify the most effective nursing interventions to decrease CLABSIs.

References

Centers for Disease Control and Prevention. (2019). Bloodstream infection event [PDF file].

Retrieved from https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf

Merrill, K. C., Sumner, S., Linford, L., Taylor, C., & Macintosh, C. (2014). Impact of universal disinfectant cap implementation on central line–associated bloodstream infections. American Journal of Infection Control, 42(12), 1274–1277. https://doi.org/10.1016/j.ajic.2014.09.00