Translational Research for Practice and Population
In the contemporary medical world, the growing insistence of institutionalizing quality and safe care has resulted in an increased reliance on evidence-based findings to inform nursing practice. That is for sure given the high number of healthcare institutions investing in evidence-based quality improvement projects. Similarly, in the author’s area of work (Trauma Intensive Care Unit, TICU) in the affiliated organization, there is a need for such a project that would better the quality of care offered. In essence, this paper aims at reflecting the same by coming up with a proposition for a practice change in the author’s affiliated organization. Central to the need for this practice change proposal is the relatively high incidence of Central Line Associated Blood Stream Infections (CLABSIs) despite the utilization of standard methods for CLABSI prevention.
Current Nursing Practice Requiring Change (Background)
Primarily, the organization of interest where the author works is dependent on soap and water for the bathing of patients in all units of the institution. Globally, such a practice is an acceptable and a minimum hygiene standard for hospitalized patients in some units of a hospital. However, the practice remains controversial in the critical care units (CCUs) given the argument that this standard practice is not useful in the prevention of infections. Instead, most modern ICUs are utilizing chlorhexidine gluconate in the daily cleaning of patients. Despite this opinion, the trauma ICU of this organization remains reliant on the utilization of soap and water in bathing of patients.
A change in the current practice in the trauma ICU is inevitable. That is for sure because of the high incidence of CLABSIs within this unit despite the use of soap and water for the bathing of patients with central vascular catheters (CVCs). As such, a change in the daily routine of patient bathing with other alternatives is of the essence if the situation is to improve for the better.
Key Stakeholders that are Part of the Nursing Practice Requiring Change
Fundamental to the carrying out of the practice requiring change are various stakeholders that are worth noting. They include the trauma ICU nurses that perform the daily bathing of patients with soap and water, the patients (recipient of the action) and the physician that authorize the use of the soap and water for bathing of the ICU patients with CVC. In essence, a change in this practice,therefore, must target these key personnel given that they are the main participants.
Evidence Critique Table
| Full APA Citation for Sources of Evidence | Evidence Strength (1-7) and Evidence Hierarchy |
| 1. Afonso, E., Blot, K., & Blot, S. (2016). Prevention of hospital-acquired bloodstream infections through chlorhexidine gluconate-impregnated washcloth bathing in intensive care units: a systematic review and meta-analysis of randomized crossover trials. Eurosurveillance, 21(46). http://dx.doi.org/10.2807/1560-7917.es.2016.21.46.30400 | 1 and Systematic review and Meta-analysis |
| 2. Frost, S., Alogso, M., Metcalfe, L., Lynch, J., Hunt, L., Sanghavi, R., Alexandrou, E. & Hillman, K. (2016). Chlorhexidine bathing and health care-associated infections among adult intensive care patients: a systematic review and meta-analysis. Critical Care, 20(1). http://dx.doi.org/10.1186/s13054-016-1553-5 | 1 and Systematic review and Meta-analysis |
| 3. Kim, H., Lee, W., Na, S., Roh, Y., Shin, C., & Kim, J. (2016). The effects of chlorhexidine gluconate bathing on health care–associated infection in intensive care units: A meta-analysis. Journal Of Critical Care, 32, 126-137. http://dx.doi.org/10.1016/j.jcrc.2015.11.011 | 1 and Meta-analysis |
| 4. Shah, H., Schwartz, J., Luna, G., & Cullen, D. (2016). Bathing With 2% Chlorhexidine Gluconate. Critical Care Nursing Quarterly, 39(1), 42-50. http://dx.doi.org/10.1097/cnq.0000000000000096 | 1 and Meta-analysis |
| 5. Swan, J., Ashton, C., Bui, L., Pham, V., Shirkey, B., Blackshear, J., Bersamin, J., Pomer, R., Johnson, M., Magtoto, A., Butler, M., Tran, S., Sanchez, L., Patel, J., Ochoa, R., Hai, S., Denison, K., Graviss, E. & Wray, N. (2016). Effect of Chlorhexidine Bathing Every Other Day on Prevention of Hospital-Acquired Infections in the Surgical ICU. Critical Care Medicine, 44(10), 1822-1832. http://dx.doi.org/10.1097/ccm.0000000000001820 | 2 and Randomized Controlled Trial with no random assignment |
Evidence Summary
Precisely, this section aims at summarizing the major findings from the reviewed articles for evidence. Primarily, Swan and colleagues, (2016) in their randomized control trial study design intended to test a hypothesis that compared the efficacy of daily soap and water as well as 2% chlorhexidine gluconate bathing on a daily basis for up to 28 days in reducing hospital acquired infections (CLABSIs included) in surgical ICU. The main findings of this study depicted a higher proportion of hospital-acquired infections in the control group for patients bathed with soap and water than in the treatment group where 2% chlorhexidine gluconate bathing intervention was present. For instance, two cases of primary bloodstream infections for patients cleaned with soap were apparent at the end of the study as compared to zero incidents in the treatment group. Finally, the researchers concluded that the use of the 2% chlorhexidine gluconate bathing resulted in absolute risk reduction by 9.0%, which is a significant statistic that can spearhead the utilization of the 2% chlorhexidine gluconate for bathing of patients (Swan, et al., 2016).
In another meta-analysis, the results were consistent with the ones of the study mentioned above. In this study, the primary objectives were to ascertain the efficacy of 2% chlorhexidine gluconate in reducing CLABSIs in adult intensive care unit and establish the cost attributes to CLABSIs and 2% chlorhexidine gluconate bathing (Shah, Schwartz, Luna, & Cullen, 2016). The researchers came to the realization that the use of 2% chlorhexidine gluconate for patient bathing resulted in a reduction of the CLABSIs. Moreover, they deduced that the cost of using 2% chlorhexidine gluconate-impregnated washcloths was ten times cheaper than the expenses incurred for managing a single CLABSI (Shah, et al., 2016). Based on these results, the researchers concluded with a rallying call for integration of such an intervention in the daily nursing practice in CCUs that aim at eliminating the CLABSIs.
Consistent with these findings are the results from another meta-analysis that included 18 studies. The focus of this study was to establish the effect of chlorhexidine gluconate bathing on healthcare-associated infections among ICU patients. In comparison to the conventional care, the researchers found out that daily chlorhexidine gluconate bathing reduced the risk of developing CLABSI significantly. Such is the case given that risk ratio for CLABSIs was 0.45, which is relatively small (Kim, Lee, Na, Roh, Shin, & Kim, 2016). With such findings, it is beyond question that daily chlorhexidine gluconate bathing is an effective method for CLABSI prevention in the modern day ICUs.
Notwithstanding, Frost and his colleagues, (2016) in their meta-analysis aimed at summarizing the efficacy of chlorhexidine gluconate bathing in decreasing CLABSI in adult ICU patients. The meta-analysis included seventeen trials, seven of which were cluster-randomized crossover trials while the rest of the studies were before-and-after trials. Of significance to their deductions was the 56% risk reduction of CLABSI secondary to the daily chlorhexidine gluconate bathing of critically ill patients (Frost et al., 2016). As such, this meta-analysis’ findings further affirms the significance of chlorhexidine gluconate bathing of ICU patients for the reduction of CLABSIs.
Lastly, Afonso, Blot, and Blot, (2016) in their systematic review and meta-analysis of randomized controlled trial they assessed the effect of 2% daily patient bathing with chlorhexidine gluconate washcloths on the incidence of hospital-acquired bloodstream infection (HABSI) and CLABSI in ICUs. The meta-analysis included four studies that concentrated on 25 ICUs constituting 22,850 patients. The researchers settled on the findings that the use of impregnated chlorhexidine gluconate washcloths resulted in HABSI rate reduction (odds ratio of 0.74). Besides, the study also identified stronger incidence reductions of CLABSIs (odds ratio of 0.50) as compared to other HABSIs (odds ratio of 0.82). According to the researchers, the possible reason for such a reduction in HABSI and CLABSI in the studied ICUs was the decrease Gram-positive skin commensals (Afonso, Blot, & Blot, 2016). Clearly, with such derivations from this study, it is beyond doubt that daily bathing of ICU patients with chlorhexidine gluconate is an effective measure for CLABSI prevention.
Specific Best Practice
Of utmost significance to this discussion is the identification of the most appropriate intervention for the prevention of CLABSIs in the trauma ICU. Going by the analyzed evidence, the specific best practice that is suitable in the author’s area of work is the use of washcloths impregnated with chlorhexidine gluconate for the bathing of patients instead of soap and water. That is for sure given the reduced numbers of CLABSIs in other settings where there is reliance on the same. For instance, Frost and his colleagues, (2016) observed in their meta-analysis that CLABSIs rates reduced by 56% after using non-rinsed washcloths impregnated with chlorhexidine gluconate in the daily cleaning of patients. With such a revelation, it is beyond doubt that replacing the current standard practice of using soap and water with chlorhexidine gluconate in bathing of trauma ICU patients will ultimately have the same effect.
Additionally, as noted by Afonso, Blot, and Blot, (2016), incorporation of other preventive strategies is of the essence to the success of this specific best practice. The other preventive strategies for combination with the chosen intervention may include hand hygiene, daily assessment of the significance of the CVC, use of aseptic technique during insertion of the CVC and utilization of CVC site dressing containing chlorhexidine gluconate. An integration of this kind will not only optimize the reduction of the CLABSIs but also improve the quality of care accorded to the patients. As such, central to the success of using non-rinsed washcloths impregnated with chlorhexidine gluconate for the daily cleaning of trauma ICU patients for CLABSI reduction is the combination of the highlighted interventions.
Practice Change Model Appropriate for the Proposed Practice Change
Central to the steering of the implementation of this proposed practice change is the commitment to change model whose understanding is vital for the evaluation of its effectiveness in driving this transformation. Characteristic of the commitment to change model are three essential components that individuals affected by a particular change will navigate in the process of change institutionalization. They include affective commitment, normative commitment, and continuance commitment. In the affective commitment, the individuals’ mindset urges them to remain in the new practice. On the contrary, the mentality of people with normative commitment reflects the sense of obligation to stay committed to the new practice. As for the continuance commitment, the perceived costs of leaving a current behavior or practice are characteristic of individuals with such a mindset (Oreg, Michel, & By, 2013).
That said, the motivating factors for the selection of this model are also worth noting in its justification as a suitable approach for the implementation of the proposed practice change. Of the essence to the selection of this model as the most appropriate for the proposed practice change is its ability to allow the implementers to evaluate the course of change implementation and establish the barriers for its institutionalization. Also, the model allows individuals to have ample time for reflection about the change implementation, which is necessary for the adoption of the required new behavior (Bouckenooghe, Schwarz, & Minbashian, 2015). Based on such features of this model, it is beyond doubt that it is the most appropriate for the implementation of the proposed change.
Finally, an illustration of the application of the commitment to change model in the implementation of the proposed practice change is also fundamental to this discussion. Primarily, the use of the commitment to change model in the implementation of the desired change proposal entails three elements that are worth mention. It begins with asking the key stakeholders to embrace the change, which in this case is daily bathing of patients with chlorhexidine gluconate impregnated washcloths. The second element is following up with the stakeholders to determine their level of commitment to the proposition. Lastly, it ends with evaluating in a later date whether or not the change forms part of the daily practice as well as determining the possible reasons for not institutionalizing the change as expected (Bouckenooghe, Schwarz, & Minbashian, 2015). With such a description, it is beyond doubt that the commitment to change model is applicable in the implementation of proposed practice change.
Possible Barriers to Successful Implementation of the Proposed Practice Change
Precisely, the implementation of the daily bathing of patients with chlorhexidine gluconate impregnated washcloths within the trauma critical care unit is not devoid of its challenges that are worth highlighting. A case in point is the increased cost for the institutionalization of such an intervention. According to Shah et al. (2016), the use of chlorhexidine gluconate impregnated washcloths resulted in higher expenditure (four times expensive) than the usual conventional practice of patient daily bathing. With such an expected increase in cost, implementation of this change proposal is thus likely to face an obstacle given the limited amount of funds available for healthcare facilities. However, in ideal situations, this should not be the case because the potential benefit of CLABSI treatment cost reduction is incomparable with the additional cost of utilizing chlorhexidine gluconate impregnated washcloths.
Another possible barrier to the institutionalization of this change proposal is the time constraint that faces nurses who have heavy workloads. That is for sure because working in an ICU is quite demanding on the side of nurses, which translates to limited time to undertake in research activities. With such absence of adequate time, incorporation of this kind of evidence-based change is problematic (Musuuza, Roberts, Carayon & Safdar, 2017). As such, this hampers the possibility of improving the quality of care.
Notwithstanding, lack of administrative support is the other likely barrier that the implementation of this change proposal is likely to face. That is for sure since the organization may opt not to back this practice by failing to avail the necessary resources for the accomplishment of this change proposal. Lack of support by the administration may be due to the perception that the practice is costly or that it is not in line with the organization’s infection prevention policy (Musuuza, Roberts, Carayon & Safdar, 2017). Based on such possibilities, it is apparent that lack of administrative support is likely to hinder the implementation of this change proposal.
Ethical Implications during Planning and Implementing the Proposed Practice Change
Of utmost significance to the planning and execution phases of the proposed practice change, are various ethical implications that the author ought to take into account for the smooth institutionalization of the modification. A case in point is the need for seeking permission from the relevant authorities to implement the change within the organization. Such an action is necessary for the avoidance of the conflict of interest between the organization and the individual members wishing to lead a change initiative within the institution (Boswell, & Cannon, 2017). As such, during the planning phase, such an arrangement of notifying the necessary authorities charged with the responsibility of ethical approval of the quality improvement project is vital.
Secondly, during implementation, seeking of consent from the targeted patients is another ethical obligation that the pioneers of this quality improvement project must bear in mind. That is for sure given the patient’s right to choose whether to take part in the study or not. Boswell and Cannon, (2017) are of the opinion that forcing an individual to participate in a study without his/her consent is unethical. Thus, there is a dire need of adhering to this ethical obligation if persons are to escape penalties of incorporating individuals in studies without their consent.
Finally, the other ethical implication during the implementation phase entails the non-use of interventions such random assignment of study participants. Such is the case given that utilization of random assignment will result in withholding known health benefits to some study subjects, which in ethical terms is wrong (Boswell, & Cannon, 2017). As such, availing of equal treatment for study participants in such cases is of utmost importance if ethical consequences are to become non-existent.
Conclusion
Concisely, this paper aimed at coming up with a proposition for a practice change in the author’s affiliated organization, which has a relatively high incidence of CLABSIs despite the utilization of standard methods for CLABSIs prevention. Largely, the discussion has achieved this objective by in-depth analysis of various issues that are worth mention. They include shedding more light on the current practice requiring change (bathing of patients with soap and water), identification of key stakeholders of the practice, as well as the determination of the best substitute for the current practice through searching and analyzing of available evidence. Moreover, it has achieved this purpose by the proposition of a practice change model that will guide the implementation of the identified specific best practice (daily bathing of trauma ICU patients with chlorhexidine gluconate). Notwithstanding, the discussion has also highlighted the possible barriers and implications of planning and implementing the proposed change.
That said, no reason of doubt exists that the proposed alteration will improve the quality of care of patients in the trauma CCU. Such is the case given that from the analyzed evidence it is apparent that introduction of daily bathing of patients with washcloth impregnated with chlorhexidine gluconate will result in a significant drop in the CLABSIs rates in the trauma ICU. As such, the implication drawn for nursing practice is the need for relying on such evidence-based findings for the improvement of the quality of care. In the absence of such dependence, healthcare challenges such as CLABSIs are likely to hinder the quality of care for the unforeseeable future.
References
Afonso, E., Blot, K., & Blot, S. (2016). Prevention of hospital-acquired bloodstream infections through chlorhexidine gluconate-impregnated washcloth bathing in intensive care units: a systematic review and meta-analysis of randomized crossover trials. Eurosurveillance, 21(46). http://dx.doi.org/10.2807/1560-7917.es.2016.21.46.30400
Boswell, C., & Cannon, S. (2017). Introduction to nursing research: Incorporating evidence-based practice.Burlington, MA: Jones & Bartlett Learning
Bouckenooghe, D., M. Schwarz, G., & Minbashian, A. (2015). Herscovitch and Meyer’s three-component model of commitment to change: Meta-analytic findings. European Journal of Work and Organizational Psychology, 24(4), 578-595.
Frost, S., Alogso, M., Metcalfe, L., Lynch, J., Hunt, L., Sanghavi, R., Alexandrou, E. & Hillman, K. (2016). Chlorhexidine bathing and health care-associated infections among adult intensive care patients: a systematic review and meta-analysis. Critical Care, 20(1). http://dx.doi.org/10.1186/s13054-016-1553-5
Kim, H., Lee, W., Na, S., Roh, Y., Shin, C., & Kim, J. (2016). The effects of chlorhexidine gluconate bathing on health care–associated infection in intensive care units: A meta-analysis. Journal Of Critical Care, 32, 126-137. http://dx.doi.org/10.1016/j.jcrc.2015.11.011
Oreg, S., Michel, A., & By, R. T. (2013). The psychology of organizational change: Viewing change from the employee’s perspective.Cambridge: Cambridge University Press
Shah, H., Schwartz, J., Luna, G., & Cullen, D. (2016). Bathing With 2% Chlorhexidine Gluconate. Critical Care Nursing Quarterly, 39(1), 42-50. http://dx.doi.org/10.1097/cnq.0000000000000096
Swan, J., Ashton, C., Bui, L., Pham, V., Shirkey, B., Blackshear, J., Bersamin, J., Pomer, R., Johnson, M., Magtoto, A., Butler, M., Tran, S., Sanchez, L., Patel, J., Ochoa, R., Hai, S., Denison, K., Graviss, E.& Wray, N. (2016). Effect of Chlorhexidine Bathing Every Other Day on Prevention of Hospital-Acquired Infections in the Surgical ICU. Critical Care Medicine, 44(10), 1822-1832. http://dx.doi.org/10.1097/ccm.0000000000001820
