Theoretical and Scientific Foundations of Nursing

DISCUSSION RESPONSE

CLARIFYING CONNECTIONS: PRACTICE PROBLEM, EVIDENCE, CHANGING PRACTICE

Respond to two colleagues  with questions to clarify or suggestions to sharpen or finesse their explanation of their problem-evidence-change initiative linkage.

PEER #1

Rose Tarantino

Introduction/Purpose

Peripherally inserted central catheters (PICCs) remain a regularly used central intravenous (IV) access device for critical care patients. This approach may be associated with weighty complications, a bloodstream infection is one of the most common consequences. Midline catheters are peripheral IV access devices that may reduce the need for central lines and decrease central line-associated bloodstream infections.  Bloodstream infections are not only detrimental to patients but are tremendously expensive to a now overburdened healthcare structure. The cost of CLABSI treatment is estimated at $32,254 per incident (Kim J, 2019). The aim of this study is to determine that mid-line catheters provide the same regimen as PICC lines decreasing the risk of bloodstream infections in critical care patients. Strategies to decrease CLABSI involve avoidance of nonessential central line placement and earliest removal when no longer indicated.  The purpose of this systematic review is to explore the evidence discussing if the use of midline catheters, in place of PICC lines and how the usage of midline catheters decreases infection. A research report has indicated that there were zero bloodstream infections identified with the main midline catheter and 10 CLABSI  have been avoided by decreasing unnecessary central line days (DeVries MPH, Lee RN, & Hoffman BSN, 2019).  A similar report maintained that midline catheters may present a feasible alternative to central venous access in certain critically ill patients (MorleyMD, WeingartMD, J.SpiegelMD, & ErasoMD, 2020). The drive of this valuation is to evaluate and determine that using a midline catheter verses a PICC line will decrease bloodstream infections in patients in the critical care environment yet providing the adequate regimen.  The research question that guided this study was “In adults in the critical care setting, does the use of midline catheters versus peripherally inserted central catheters decrease the risk of bloodstream infections while providing the same medical regimen?”

Review of Literature

            It is crucial for healthcare providers to become educated at lowering the risk of bloodstream infections for critical care patients.  The healthcare providers must be provided information that choices between a midline catheter and a peripherally inserted central catheter exists and the choice may decrease the potential for bloodstream infections. Morley et al (2018) conducted a prospective observational case study of all patients who had a midline catheter insertion January 28, 2016, to December 30, 2017. The attending physicians and residents were trained on proper patient and vessel selection and insert techniques. The mean dwell time was 6.7 days, 403 midline catheters were placed, two reviewers using the EMR system with an allotted area for potential bloodstream infections concluded that zero catheter bloodstream infections associated with midline catheter insertion were observed. 

The methods that DeVries et al (2019) used was design prospective monitoring of the implementation for a quality improvement project. The setting was a 576 bed, urban, community, nonprofit, Magnet recognized, level 3 trauma center serving primarily adult patients. Midline and peripherally inserted central catheters were inserted by a specialty nursing team; care and maintenance of all devices were provided by front line staff. The results were that there were zero midline catheter infections were observed in the 24 months after implementation of the fixed length, power injectable device. Completion of therapy was 80%, the most frequently encountered complication was device dislodgement. Stemming from this study was midline catheter program, allowing the ability of the team to select the right device for the patient, while decreasing excess central line usage without additional increased risks to the patient.

In a retrospective study conducted over 12 months in a multi-hospital system by Hogle et al (2019) showed the incidence of bloodstream infections associated with midline catheters was not significantly lower than that associated with central venous catheters however they implemented a program utilizing midlines as opposed to central line. The new findings suggest that the hospitals involved in this study have reported lower rates of CLABSI following implementation of their ML program.  This was a retrospective surveillance study conducted in the 5 acute care hospitals of a large urban medical system from September 2016 to August 2017.  Data were collected using hospital electronic medical records. CLABSI and MLABSI cases were identified as part of routine surveillance for health care–associated infections conducted by trained infection preventionists at the participating hospitals (Hogle MPH, Balzer MSN, Ross MS, & MD, 2019).

The focus of the data (Mushtaq, et al., 2018) used a retrospective cohort study that was performed at a tertiary care hospital in Detroit, Michigan, from March-September 2016. Adult patients with either MC or CVC were included. Outcomes assessed were catheter-related BSI (CRBSI), mechanical complications, hospital length of stay, readmission within 90 days of discharge (RA), and mortality. Statistical analysis was performed using SAS software (Mushtaq, et al., 2018).  A total of 411 patients with MC and 282 patients with CVC were analyzed. More CRBSIs were seen in patients with CVC (10/282) than MC (1/411). This showed that use of Midlines is safer than PICC lines.

In 2016, (Xu, et al., 2016) produced retrospective study comparing the use and outcomes of PICCs and MCs at a large academic medical center between January and May 2015. Data were collected using electronic medical records and IV team insertion data. Statistical software was used for analysis (Xu, et al., 2016).  A total of 206 PICCs and 200 MCs were inserted in 367 patients within the study duration.  Midlines were associated with a higher risk of non–life-threatening complications such as dislodgement versus PICCs, which showed fewer but more serious complications, including bacteremia.

Another study by Patel et al (2019) conducted their study in an institution is a 470-bed tertiary care, safety-net hospital in Chicago, Illinois.  They retrospectively collated electronic requests for midline catheter insertions on adult inpatients between October 2015 and June 2017.  Every midline recipient’s history of deep vein thrombosis (DVT) and catheter-related infection (CRI) was recorded. Procedural information (e.g., inserter, vein, and number of attempts) was obtained from insertion notes (Patel, et al., 2019). All data were extracted from the electronic medical record via chart review. Two reviewers confirmed outcomes to confirm concordance with stated definitions (i.e., DVT, CRI). Other parameters, including dwell time, indications, and time to complication(s) were also collected. There was one positive blood culture sampled immediately within 48 hours after catheter removal, but it had no infectious focus explaining the positive blood culture result.  Their conclusion states “In patients requiring short-term IV therapy, these data suggest midline catheters have low complication rates and may be safely used as an alternative option for venous access”.

            The focus of Pathak et al (2018) study was concluded by stating, “The addition of the midline program to replace central lines whenever possible, combined with universal CDC recommendations, did result in a significant decrease in both the number of central line days per patient-day and the CLABSI rate”.  How they went about obtaining this information was that they collected data on the number of central line catheter-days per year starting in 2014, also collecting data on the total number of patient-days during the same time frame and the number of CLABSIs. They initiated at the same time frame the Centers for Disease Control and Prevention (CDC)-based recommendations to help decrease CLABSIs counting the PICC lines placed and the midlines placed comparing the rate of infection from both.  This was a retrospective review of the data collected over the past 5 years from their infection control department.  Then they initiated a midline program in June 2015. With the introduction of this program, they stated that they replaced central lines in the hospital whenever possible by midlines. All emergency central lines and central lines placed for total parental nutrition and ionotropic medications were replaced when possible by midlines.  They concluded by stating, “Midlines decreases the incidence of CLABSI and the associated costs to the hospital” (Pathak, Gangina, Jairam, & Hinton, 2018).

Methodology

For this research review , critically appraised research studies were obtained by judiciously pulling articles from Walden University library sites such as CINAHL and PubMed MEDLINE. Using the Boolean phrases; peripherally inserted central catheter, infection, midline catheters and CLABSI, this turned up over 350 articles.  I then went back and used a timeframe from 2016-2020.  This eliminated most of the articles by the time frame. The next half was surrendered due to lack of credibility, an example was that the article mentioned a brand consistently.   My articles are peer reviewed; I have held in reserve twelve journal articles, appropriately addressing the correlation between PICC lines, midlines, and bloodstream infections and the importance of initiating a midline program. 

Evaluation/Recommendation

 The results concluded that using midline catheters as a first line approach in critical care patients for vascular access instead of using a peripheral inserted catheter does reduce the risk of bloodstream infections.  The studies have proven to be concise and is in accordance with the CDC.  There was a significant decrease in the total number of bloodstream infections because of the use of midline catheters.  Hospitals now institute a policy questionnaire when deciding which access to initiate in their critical care patient.  Many facilities initiated a midline program that decided if a midline was ok as opposed to a PICC line.  Midline catheters that are used in place of central lines decrease the rate of bloodstream infections in a critical care patient. This is an important study because midlines do not lie in a central vein and are not considered central lines, but the provide the necessary regime for the critical care patient without the risk of bloodstream infections. Patients are given central lines, when a midline is safer and effective.  In the future, I would take into consideration the medications or infusions that require central line-only administration, for example: total parental nutrition, chemotherapy and those medications that are authorized for central line administration only.  

References

DeVries MPH, C. V.-B., Lee RN, J., & Hoffman BSN, R. V.-B. (2019, September). Infection free midline catheter implementation at a community hospital (2 years).  American Journal of Infection Control, 47(9), 1118-1121.

Hogle MPH, R. N., Balzer MSN, R. K., Ross MS, R. C., & MD, C. (2019). A comparison of the incidence of midline catheter–associated bloodstream infections to that of central line–associated bloodstream infections in 5 acute care hospitals.  American Journal of Infection Control, 50-58.

Kim J, H. P. (2019). Reduction of Catheter-related Bloodstream Infections through the Use of a Central Venous Line Bundle: Epidemiologic and Economic Consequences.  American Journal of Infection Control, 640-646.

MorleyMD, J., WeingartMD, S., J.SpiegelMD, R., & ErasoMD, D. (2020, April). The Utility of Midline Intravenous Catheters in Critically Ill Emergency Department Patients.  Annals of Emergency Medicine, 75, 538-545.

Mushtaq, A., Navalkele, B., Kaur, M., Krishna, A., Saleem, A., Rana, N., . . . Surapaneni, M. (2018, July). Comparison of complications in midlines versus central venous catheters: Are midlines safer than central venous lines?  American Journal of Infection Control, 46(7), 788-792.

Patel, S., Araujo, T., Rodrigues, L., Sanchez, C., Snyder, A., & Chopra, V. (2019). Long Peripheral Catheters: A Retrospective Review of Major Complications.  Journal of Hospital Medicine, 758-761.

Pathak, R., Gangina, S., Jairam, F., & Hinton, K. (2018). A vascular access and midlines program can decrease hospital-acquired central line-associated bloodstream infections and cost to a community-based hospital.  Dove Press, 1453-1456.

Xu, T., Kingsley, L., DiNucci, S., Messer, G., Jeong, J., Morgan, B., . . . Yassin, M. (2016, December). Safety and utilization of peripherally inserted central catheters versus midline catheters at a large academic medical center.  American Journal of Infection Control, 44(12), 1458-1461.

PEER #2

Idiat Oyefunke Falade

Initial Posting

The practise problem is fall in elderly in healthcare. Falls among elderly patients in healthcare settings present a significant concern for patient safety, leading to adverse consequences such as fractures, prolonged hospital stays, and increased healthcare costs. Several factors contribute to the higher incidence of falls in this age group, including limited mobility, visual impairment, balance issues, medication-related side effects, and cognitive decline. Implementing nursing practices can play a pivotal role in mitigating the prevalence of falls in this vulnerable population. A study by Tajane et al. (2021) emphasizes the gravity of the issue of falls in elderly patients, with ample literature supporting the link between falls and detrimental outcomes.

The specific problem under consideration is "Patient Safety," with a focus on the issue of "Falls among Elderly Patients." The PICO question is structured as follows:

· Population: Elderly patients aged 65 and above, who are at high risk of falling while in a healthcare facility.

· Intervention: The intervention involves the implementation of preventative measures aimed at reducing falls among elderly patients. These measures include regular risk assessments, ensuring adequate lighting, and utilizing adaptive equipment.

· Comparison Group: The comparison group comprises elderly patients aged 65 and above who do not receive these interventions.

· Outcome: The desired outcome is a decrease in the occurrence of falls among elderly patients across various clinical environments and settings.

Synthesis of Evidence and the Need for a Practice Change Initiative

Patient falls are a significant concern in healthcare, often resulting in injuries, prolonged hospital stays, increased healthcare costs, and diminished patient outcomes. This synthesis of evidence will explore the current state of knowledge surrounding patient falls in healthcare and demonstrate the necessity for a practice change initiative to address this critical issue.

1. Prevalence and Consequences of Patient Falls:

Patient falls are alarmingly common in healthcare settings, with an estimated 700,000 to 1 million falls occurring annually in U.S. hospitals alone (Oliver et al., 2010). These falls lead to a variety of adverse consequences, including:

Physical injuries such as fractures and head injuries.

Psychological trauma for patients and families.

Prolonged hospital stays and increased healthcare costs.

Legal liabilities for healthcare institutions.

Diminished patient trust and satisfaction (Currie & Haines, 2010).

1. Contributing Factors:

Numerous factors contribute to patient falls, including patient-specific risk factors and environmental factors within healthcare facilities (Tzeng, 2010). Common risk factors include:

Age-related factors, as older adults are at greater risk.

Impaired mobility and balance.

Cognitive impairment or confusion.

Medication-related issues, such as side effects.

Inadequate staffing and supervision (Coussement et al., 2011).

1. Existing Interventions and Their Limitations:

Healthcare facilities have implemented various interventions to prevent falls, such as fall risk assessments, bed alarms, and patient education. However, the evidence suggests that these interventions have limitations:

Inconsistent implementation of fall prevention protocols.

Over-reliance on bed alarms, which may lead to alarm fatigue.

Failure to address environmental hazards adequately (Dykes et al., 2018).

Limited effectiveness in reducing falls, as falls continue to occur at alarming rates.

1. The Need for a Practice Change Initiative:

To address the ongoing issue of patient falls in healthcare, a practice change initiative is necessary. This initiative should encompass the following components:

Evidence-Based Practice: Implementing evidence-based fall prevention strategies tailored to individual patient needs (Coussement et al., 2011).

Multidisciplinary Approach: Collaborating across healthcare teams to identify risk factors and develop comprehensive care plans (Currie & Haines, 2010).

Environmental Modifications: Identifying and mitigating environmental hazards to reduce fall risks (Dykes et al., 2018).

Staff Training: Ensuring healthcare professionals are well-trained in fall prevention strategies and are aware of their role in reducing patient falls..

Strength of Evidenced Based

The evidence highlighting "Falling among Elderly Patients" as a significant challenge in nursing practice is robust. Extensive research supports the notion that falls pose a substantial problem for the elderly, particularly in healthcare settings. A multitude of studies consistently demonstrate that falls represent a major source of injuries and fatalities among older adults (Ekvall Hansson & Magnusson, 2015). Furthermore, falls in the elderly can lead to various complications, including hip fractures, head injuries, and diminished independence. These complications can result in increased healthcare expenses, prolonged hospital stays, and reduced quality of life for older individuals.

Suggestion practice change based on Evidenced.

Drawing upon comprehensive fall risk assessments and the available body of research, it has been established that the introduction of fall prevention protocols, the provision of education to both caregivers and patients regarding fall prevention strategies, and the utilization of assistive devices to enhance mobility and reduce the risk of falls are effective measures. Furthermore, it is crucial to provide training to nursing staff so that they can adeptly identify individuals who are susceptible to falls, including those with cognitive impairments and those experiencing adverse drug reactions (White, Dudley-Brown & Terhaar, 2019).

Conclusion

To conclude, there is a wealth of research on "Falling among Elderly Patients" as a nursing-related issue. Injuries, hospitalizations, and a lower quality of life are all serious outcomes of falls, which are a significant problem for older adults. The best way to prevent falls is a multifactorial strategy, which is why nurses are crucial in determining, assessing, and controlling fall risk factor.

 

References:

Bureau of Labor Statistics. (2020). Registered nurses: Occupational outlook handbook.

Retrieved from <https://www.bls.gov/ooh/ healthcare/registered-nurses.htm>

Health Resources and Services Administration.

(2020). The nursing workforce. Retrieved from <https://www.hrsa.gov/workforce/nursing/ index.html>

Currie, L., & Haines, T. P. (2010). A systematic review and meta-analysis of studies on the prevention of falls in hospital settings. The Journals of Gerontology: Series A, 65(7), 712-721.

Coussement, J., De Paepe, L., Schwendimann, R., Denhaerynck, K., & Dejaeger, E. (2011). Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis. Journal of the American Geriatrics Society, 59(8), 1483-1495.

Dykes, P. C., Carroll, D. L., Hurley, A. C., Benoit, A., & Middleton, B. (2018). Why do patients in acute care hospitals fall? Can falls be prevented? Journal of Nursing Administration, 38(6), 299-302.

Ekvall Hansson, E., & Magnusson, L. (2015). The frequency of falls among the elderly in institutional care and during a hospital stay: An explorative study. Scandinavian Journal of Caring Sciences, 29(1), 47-56.