EBT1: Evidence Based Practice and Applied Nursing Research COMPLETE COURSE WGU RN-BSN

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TASK 1 The research obtained in this particular study does support the conclusion. When all five area’s were studied, it verified that the incidence of ventilated associated pneumonia was decreased when oral care and dental care was performed onto these mechanically ventilated patients. The background information that was provided was direct, to the point and relevant to the impact of today’s heath care. Millions of dollars are being spent every year for incidences within hospitals that can be prevented and this study was set out to prove just that, that ventilator associated pneumonia can be prevented. The logic was simple. That logic was to clear the mouth and airway of any harboring microorganisms that can pool in the mouth and result into an infection. The test groups were relevantly the same size and the characteristics of age, sex, APACHE scores and reasons for admissions were comparable. The conclusion was predictable in verifying that strict oral cleaning did result in a lower incidence of ventilator associated pneumonia in patients.
A.4.
During the course of this research, ethics would be addressed. Before the study had begun, the Infection Control Department had meetings with nurses and doctors of the ICU, nurse educators, anesthesiologists, emergency room staff, Materials Management and the performance improvements departments to discuss and explain this study. There would be very strict criteria in order to be enrolled into this study. This criteria was that the patient would be admitted into the medical intensive care unit and be intubated for more than 48 hours in order to be eligible. Ventilated patients would be considered a vulnerable population but there was no discussion of an informed consent for this particular study although it is normal protocol to have consent for treatment signed upon being admitted into the hospital which inadvertently may include consent for studies. This study would not do any harm to the patient per se. The first group who received no oral care would get just that, no oral care while being mechanically ventilated. Both test groups were approximate in size and all characteristics such as age, sex, APACHE score and reasons for hospitalizations were comparable. The integrity was evident in wanting to do this research as the researchers wanted to prove that improvement to outcomes would be evident with doing oral care on mechanically ventilated patients. The study showed respect towards its subjects as it did not release any names or identifiable information about the participants when the results were published.
A.5.
The study was quantitative in nature. The study clearly described the effect of oral and dental care on patients receiving mechanical ventilation. A group of 779 patients were studied before interventions were given. This particular group received no oral care which included suctioning, tooth brushing and removal of secretions from the oral cavity. A group of 759 patients were studied during the intervention as they were given a strict protocol of oral cleansing, tooth brushing and suctioning every 4-6 hours. I do not feel a qualitative method would have provided the same results as the study was not focused on a phenomenon. TASK 2

• 1. Clinical practice guideline: Diagnosis and management of acute otitis media.
• This is a filtered source.
• This article is appropriate for clinician who is able to diagnose and prescribe, but not for nurses to as they do not diagnose not do they prescribe. This article does offer excellent information on what to assess in the different scenarios it presents and recommendations to those particular scenarios. It would be outside the scope of practice to apply these recommendations listed as this would be more appropriate for an advanced level Clinician.
• This article is considered an evidence-based guideline.

• 2. Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media.
• This is a filtered source.
• This article is appropriate for an advanced level clinician as they diagnose and prescribe. However, this article does offer excellent detailed information on cultures and what would be best to treat acute otitis media. It is a little too advanced for basic nursing assessment.
• This article is considered to be an evidence summary.

• 3. Current pediatric diagnosis and treatment
• This article is considered a generalsource.
• This article is appropriate for a nursing practice situation as it describes what acute otitis media is and how to assess it and treat it. It is direct and to the point of what to assess and the rationale of its findings.
• This article is considered NOT considered primary research evidence, evidence summary or evidence based guideline. It is none of these.

• 4. Treatment of acute otitis media in the era of increasing microbial resistance.
• This article is an unfiltered source.
• This article is appropriate for a nursing practice situation simply because it gives some history as to why acute otitis media may be resistant to traditional therapies. Other subjects within this article in regards to what to order would be more appropriate for advanced level clinicians.
• This article is considered an evidence-based guideline.

• 5. Interviews with parents who have brought their children into the clinic for otitis media.
• This would be considered a generalsource
• The interview with the parent of a child can be beneficial in regards to disclosing the childs health history. The parent can usually give an accurate answer the child has had otitis media in the past. The reason that this is beneficial is that it reduces time and money in obtaining medical records only to learn that the parent has given the same information. (Vernacchio, Vezina, Ozonoff & Mitchell, 2006)
• Interviews are NOT considered primary research evidence, evidence summary or evidence based guideline. It is none of these.

B. Appropriateness of Clinical Practice Guideline Review

In reviewing the clinical practice guidelines, there are many valid points that can be utilized effectively. It clearly outlines differentiations between observation and treatment, when to treat and for what condition. It emphasizes the point that the condition must be accurately diagnosed in order to be treated correctly. In certain instances, a watchful waiting is an appropriate approach to caring for a child with Acute Otitis Media. We do live in a society where medication is prescribed for many conditions which are unnecessary. It not only is unnecessary medicating a burden on an immune system, it is taxing to the cost of healthcare and “indirect cost due to time lost from school or work”. (American Academy of Pediatrics, 2004) Unless there is an underlying condition, it is recommended that observation of the condition be done in lieu of prescribing antibacterial agents (American Academy of Pediatrics, 2004). In these types of scenarios, the patient may improve without the aid of medication. These guidelines give clear and concise examples of when it is appropriate to medicate patients that would not benefit from watchful waiting.

TASK 3

1. Topic chosen: Routine Shaving prep of the surgical site
1. The shave prep for a surgical site entails of actually removing hair from the skin with a razor prior to surgery. In order to do shave prep, you would get the skin wet and lathery and begin to shave with a disposable razor. You shave in short clean strokes to eliminate any hair from being torn from the follicle. The shave prep should be done while wet because a dry shave prep increases the possibility of skin irritation and cuts.
I believe this technique should be changed as it actually increases the risk of nosocomial infection and removes the normal body flora. 1. Interviewing hospital personnel, I learned the following:
1. The Chief of Staff determines what procedures can and cannot be done in the surgical realm.
2. It was explained to me (since I was not able to speak with the Chief of Staff) that the rationale for this particular type of procedure was to ensure that no microbes were attached to the hair shaft and follicles. It is believed that if there is no hair at all and the area is appropriately cleaned, there is no chance of infection to these sites.
3. The reason why this practice is performed this way is because this is how it has been for 15-20 years. It was relayed to me that Physicians in this particular surgical environment are somewhat on the resistant side to change. 1. Literature Review:
1. Adewale, A., Olukayode, L., & Olusanya, A. (2011). Evaluation of two methods of preoperative hair removals and their relationship to postoperative wound infection.Journal of infection in developing countries, 5(10), 717-722.
2. Dizer, B., Hatipoglu, S., Katmakcioglu, N., Tufran, T., Yava, A., Iyigun, E., & Senses, Z. (2009). The effect of nurse performed preoperative skin preparation pn postoperative surgical site infections in abdominal surgery. Journal of clinical nursing, 18, 3325-3332.
3. (2008). Pre-operative hair removal to reduce surgical site infection. Australian Nursing Journal, 15(7), 27-29.
4. (2006). Razors versus clippers in preoperative hair removal.Nursing Standard, 20(20), 18-19.
5. Odom-Forren, J. (2006).Preventing surgical site infections. (Vol. 36, pp. 58-64).
2. Based on the review of these literary pieces, it appears to be unanimous that if hair needs to be removed, then clippers and depilatory creams demonstrate fewer infections at the surgical site. The reason for this is utilizing a razor to remove hair from a surgical site predisposes to skin injuries and can result in wound infections.
By utilizing clippers and depilatory creams, it prevents the surgical site from getting any unnecessary nicks which would be a portal of entry for microorganisms to enter. 1. By adopting the clipper procedure, various costs would be virtually eliminated. These costs include the razors themselves but also the cost to treat and care for the patient who contracts a surgical site infection. 1. When proposing any type of change in a health care setting, there are many stakeholders. These stakeholders include: the Chief of Staff, physicians, nurses, CNA’s, materials management, nurse educators and anyone involved in the direct patient care. The issue that needs to be addressed should be discussed first. It is important to set the scene as to what the issue is before presenting how to change that issue. In the example of routine Shaving prep of the surgical site, the issue to be brought to everyone’s attention would be how technique should be changed as it actually increases the risk of nosocomial infection and removes the normal body flora. To back up the claim of the increased risk of infection, present the group with statistics of the amount of patients developing infection at the shaved site. Once this information has been relayed, this would be the prime opportunity to present research studies indicating that clippers and depilatory creams demonstrate fewer infections at the surgical site. Since nursing is an evidence based practice, it is vitally important to show these results in order to be a catalyst to change. Stakeholders must have trust in what is being presented in order to gain support for a change. By involving anyone who would be involved in this type of practice change, it is important to allow them to voice their concerns and ask questions. By seeking feedback, this will show the stakeholders that their contributions are recognized. This will not only build trust, it can enhance working relationships and communication amongst the health care team. To deliver a proposal for a change in protocol, it is important to show exactly how we are doing a procedure now. Once that has been established, you want to direct the stakeholders towards the vision of what kind of change you want to make and explain how we make this change and what the end result will be. In this particular instance, I would outline how shaving a surgical site can increase the risk of an infection. I would present the studies that have been conducted to prove that hair clipping can be effective instead of shaving as evidenced by the decrease in nosocomial infections. If we are indeed granted the ability to change this practice, we will know it has been successful when there is a decrease in infections and in turn saving the hospital money due to these related costs.

EBT Task 1 Matrix Author Source Date (year) Research Type Population/Sample size Outcome Measures Pertinent data from results Suggested Conclusions Comments
(Garcia, Jendresky, Colbert, Bailey, Zaman & Majumber, 2006) American Journal of Critical Care/located in CINAHL 2006 Experimental Conducted in a university-affiliated medical center.
Group studied before interventions were 779 and group studied during the intervention was 759. Oral/dental care decreased the rates of ventilator associated pneumonia. Compliance with protocol exceeded 80%. Rates of VAP was 12 per 1000 days before intervention and decreased to 8 per 1000 days during intervention. Incidence of VAP decreased in patients receiving oral/dental care.
(Halm & Armola, 2009) American Journal of Critical Care/located in CINAHL 2009 Quasi-experimental 7 random trials from diverse ICU’s were studied and included, toothbrushing and/or chlorhexadine used at various frequencies to assess if it helped decreasing VAP. Toothbrushing decreased the incidence of VAP. Chlorhexadine had no effect on one study. Toothbrushing decreased the incidence of VAP.
(Tolentino-DelosReyes, Ruppert, Yun & Shiao, 2007) American Journal of Critical Care/located in CINAHL 2007 Quasi-experimental 61 nurses in study from coronary care unit and surgical ICU. Increasing staff knowledge about how to prevent VAP decreased the incidence of VAP in patients. Increasing staff knowledge about how to prevent VAP decreased the incidence of VAP in patients. Increasing staff knowledge about how to prevent VAP decreased the incidence of VAP in patients.
(Munro, Grap, Jones, McClish & Sessler, 2009) American Journal of Critical Care/located in CINAHL 2009 Quasi-experimental Conducted in Richmond, Virginia. 2x2 factorial design was used. Group studied was 547 people. Chlorhexadine reduced early VAP in patients without pneumonia at baseline 4 groups did not differ significantly in characteristics. Day 3; 249 patients remained in study. Patients without pneumonia at baseline developed it on Day 3. Toothbrushing did not reduce VAP. Incidence of VAP decreased in patients receiving oral/dental care. Informed consent was obtained on all participants from a legal representative.
(Hsu, Liao, Li & Chiou, 2010) American Journal of Critical Care/located in CINAHL 2010 Quasi-experimental 81 patients in medical center ICU in northern Taiwan Oral care using boiled water and green tea Incidence of VAP decreased in patients receiving oral/dental care. Incidence of VAP decreased in patients receiving oral/dental care. Study supported that increasing oral care decreased incidence of VAP.
(Kingston, 2007) American journal of nursing/located in CINAHL 2007 Time series study 9,080 patients were studied between 06/06/2005-06/06/2006 Oral care and ventilator bundle utilized resulting in decreased VAP. Oral care and ventilator bundle utilized resulting in decreased VAP. VAP was decreased
(Evans, 2005) Nursing management/located in CINAHL 2005 Casual comparative designs 700 bed tertiary hospital in Rochester, NY with 17 ned medical ICU. Utilizing the “bundle” approach in decreasing VAP. Utilizing the bundle approach decreased the incidence of VAP. VAP was decreased