Data Collection/Analysis

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Quantitative Synopsis and Appraisal

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College of Nursing, Resurrection University

NUR4440: Research in Nursing

Professor Carina Piccinini

February 14, 2020

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Quantitative Appraisal and Synopsis

The purpose of this paper is to summarize and appraise a research study testing the use of

disinfectant caps on intravenous (IV lines) to reduce the 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 CDC (2019)

recommends proper maintenance of intravenous lines to reduce the risk of infection. Current

research is still looking to define what proper maintenance should be, including whether

disinfectant caps influence rates of infection for intravenous (IV) lines.

Summary of the Study

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 of this study note other

studies have tested disinfecting caps and sought to confirm those results.

Merrill et al. (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 by

including all patients meeting inclusion criteria at the hospital starting January 2012. Participants

were included if they had a central or peripheral intravenous line, of any age, and were 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

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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 ports on

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 by the

researchers. Nurses were then responsible for placing caps. The researchers intermittently

observing nurses for compliance to the intervention and reporting 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 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 CLABSI rate would not be

skewed positively by short-term IV access. If these care areas had been included, the dwell time

of the line, not the presence or absence of the Curos caps would logically be the primary cause of

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a low CLABSI rate.

Intervention fidelity was met through training the nurses and 1:1 follow-up. However, the

mere fact that compliance rate was audited indicates that intervention fidelity, i.e. compliance

with the intervention, was questionable. In addition, the authors did not include the actual

compliance rate of the intervention in the article, which affects the credibility of the overall

findings.

Although the measurement of CLABSIs using medical records has inherent bias, it was

the only feasible way to obtain the data. Missing data in the medical record was not reported by

the researchers, which affects the validity of the data. The researchers did not explain fully how

they observed if the disinfectant caps were on all patients or how compliance was counted,

leading to a reliability issue. 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.

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 difference in mean rates

before and after the intervention was not tested for statistical significance. Using a different

statistical method, the authors found that the incident rate ratio after implementation was

statistically significant, causing a 40% drop in BSIs. The authors acknowledged that ongoing

education about reducing BSIs and using central line bundles was given to nurses independent of

the study protocol. This extraneous variable was not measured nor included in the results or

conclusions of the study, leading to a large chance of bias in attributing the CLABSI decrease to

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the disinfectant cap intervention alone.

Conclusion

This study indicates that disinfectant caps could reduce rates of bloodstream infections.

However, given the fact that certain aspects of the study as explained in the appraisal may have

influenced results in favor of disinfectant caps, more research with fewer extraneous variables

interfering with results needs to be conducted.

Although the difference in CLABSIs before and after the intervention was not tested for

significance, there is evidence of a reduction in BSIs in this study, and the CDC (2019) does

recommend disinfection to BSIs in hospitals. Therefore, the implications of this and other

research exploring the same issue is that nurses should be compliant with existing facility

protocols for intravenous line maintenance, regardless of the method used. Nurses should also

advocate for all patients by providing reminders and education to peers that do not adhere to

protocols or best practices, as they are now defined. Nurses could also advocate and participate

in hospital-based studies to test nursing interventions intended to decrease BSIs.

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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