Running head: RESEARCH CRITIQUE: BLOOD STREAM INFECTIONS

Research Critique
Tom Jones
Texas A&M University-Corpus Christi
School of Nursing
Nursing Research 5314
Fall 2005 Research Critique
Introduction
Blood stream infections associated with central venous catheters account for approximately 250,000 infections in the United States annually. The vast majority of these infections are preventable through education on best practice (Coopersmith et al., 2004). Best practice principles include hand washing, maximum sterile precautions, and labeled catheter dressings. Central venous catheters are routinely used in the critical care setting; therefore, posing an increased risk of infection. Furthermore, increases in morbidity, mortality, and cost are a result of blood stream infections from central lines (Warren et al., 2004).
Research Problem Blood stream infections increase morbidity, mortality, cost, length of stay; furthermore, the literature shows that many of these infections are preventable. A staff education has proven to be cost effective and proficient in decreasing blood stream infections (Coopersmith, et al., 2004). Warren et al. (2004) states, “The Centers for Disease Control (CDC) recommends the utilization of health-care worker education is an important element in programs aimed at the prevention of hospital-acquired infections” (p.1613). A review of the literature explain nurse bedside behavior after education on hand washing and best practice with central venous catheters can decrease blood stream infections.
Purpose
The purpose of the research was to create an educational curriculum for nurses to practice best practice while caring for patients with central venous catheters. The purpose for the education is to decrease blood stream infections by changing the bedside nurse’s behavior to follow best practice while caring for central venous catheters (Coopersmith et al., 2004). Problem Statement A research problem statement has been constructed after reviewing the literature: Education on hand washing and best practice can decrease blood stream infections due to changes in nursing behavior (Coopersmith et al., 2004). The research suggests that the blood stream infections are directly related to bedside nurse’s behavior. Blood stream infections increase morbidity, mortality, cost, and length of stay; furthermore, the literature reviewed shows that many of these infections are preventable. A staff education has proven to be cost effective and proficient in decreasing blood stream infections (Coopersmith et al., 2004). Education modules on hand washing and best practice on central venous catheter care can change nursing behavior; therefore, striving for blood stream infection reduction. Mortality ranges from 12-25% for every central venous catheter blood stream infection. Blood stream infections are very expensive to treat. Blood stream infections increase cost, length of stay, and morbidity. For that reason, it is important to focus on educating nurses on techniques to reduce infection (Coopersmith et al., 2004).
Research Question (Question vs. Hypothesis) Would a decrease in blood stream infection be observed in the institution after an education program focused on hand washing and best practice? The hypothesis stipulates that by educating nurses on best practice principles and hand washing, blood stream infection rates will decrease. The hypothesis predicts that the education modules on hand washing and best practice principles will have an impact on reducing blood stream infection rates. The hypothesis has a testable construction since the variables mentioned are observable and measurable (LoBiondo-Wood & Haber, 2002).
Variables
According to Polit and Beck (2004), variables are items under investigation that have no constant. The research reviewed identifies several variables such as hand washing, maximal sterile barrier precautions, and catheter dressing changes (Coopersmith et al., 2004). The investigators make an effort to find the cause, effect, and resolution to the research problem of blood stream infection. The study reviewed describes the variables as “best practice” nursing behavior and incidence of blood stream infection from central venous catheters. Haber (2002) states, “An independent variable is the variable that has the presumed effect on the dependent variable” (p. 57). In this study, the independent variables are the education modules and “best practice” nursing behavior. Haber (2002) states, “ A dependent variable is the consequence or the presumed effect that varies with a change in the independent variable” (p. 57). In this study, the dependent variable is the occurrence of blood stream infections. Blood stream infection (dependent variable) is the presumed effect of altered nursing behavior that occurred after education (independent variables). Furthermore, the research reviewed showed that when nurses performed hand washing and best practice principles, blood stream infections rates were lowered (Coopersmith et al., 2004).
Supporting Literature Coopersmith et al. (2004) research utilized bedside audits to primarily confirm bedside behavior compliance. Bedside audits were conducted in a Surgical Intensive Care Unit at Barnes-Jewish Hospital at Washington University School of Medicine. A multidisciplinary team made behavior observation audits without the staff’s knowledge, to prevent behavior alterations. The bedside audits were randomly selected during the 39-month time frame (Coopersmith et al., 2004). The bedside audits did enable some control, because the bedside nurses did not know if or when they were being observed. Therefore, bedside behavior compliance would be increased due to known audits. Also, by utilizing the information from the pre and post-test, the researchers identified the educational focus on central venous catheter management. Coopersmith et al. (2004) used other sources such as Centers for Disease Control and National Nosocomial Infection Surveillance definition and related issues on cause and effect of blood stream infections. Also, the data gained from the bedside audits were compared to the Fisher exact test and Mann-Whitney test (Coppersmith et al., 2004). However, the detailed descriptions and significance of these tests were not given.
Conceptual Model Coopersmith et al. (2004) research did not identify a conceptual model. However, a conceptual model that describes behavior would be appropriate such as Dorothy Johnson’s Behavioral System Model. According to Fawcett (2005), “Johnson explained that the Behavioral System orientation leads nursing to fulfill its social mission through the special responsibility of promoting the most effective and efficient behavioral system possible, as well as to prevent specific problems from occurring in the system” (p. 61-62). In Coopersmith et al. (2004) study, the researchers predict a reduction of blood stream infection by changing nursing behavior after self-study modules have been reviewed. Johnson’s Behavior System’s model has four structural elements such as goal, set, behavioral choice, and the action or behavior (Fawcett, 2005). These four elements would be beneficial for nurses to utilize after the education to consider on the behavior needed to reduce blood stream infection.
Research Design The researchers chose a before-after trial research design for this study. This design is considered a times series design because nurses took a pre-test and post-test. The pre-test provided the researchers with the nurses’ baseline knowledge on central venous catheter management. The post-test results showed the nurses’ increased knowledge on central venous catheter management after an educational program was implemented. According to LoBiondo-Wood and Haber (2002), “one approach used by researchers when only one group is available is to study that group over a longer period. This quasiexperimental design is called a time series design” (p.213). Coopersmith et al. (2004) study was over a period of 39 months in the same Surgical ICU setting. The only group studied for bedside behavior compliance was the Surgical ICU staff. This research design is appropriate for this study, because the relationship between best practice principles compliance and infection rate reduction are established. Also, pre and post-tests were an excellent way to evaluate nursing knowledge. The researchers were able to utilize this information for their educational program focus due to their increased concern of blood stream infections (Coopersmith et al., 2004). Furthermore, the research design and the research question are a cohesive fit, as the increase in compliance was demonstrated after education was implemented.
Sample
Coppersmith et al. (2004) selected all patients admitted to the Surgical ICU with the same demographics to enroll in the study from January 1, 1998 and September 30, 2002. The designated infection control team monitored these patients for the occurrence of a blood stream infection. At the beginning of the study, the Surgical ICU was an 18-bed unit, but during the study the ICU added more beds. Furthermore, this ICU normally admits 1400 patients/year with an average stay of 4.3 days. The blood stream infections were placed in either a primary or secondary infection category as per the NNIS definitions. The infection rates were compared with the national data at monthly meetings (Coopersmith et al., 2004). Bedside audits were done randomly to check for catheter management compliance. In November 2000 through January 2002, the designated staff performed the initial bedside audit. With the information obtained from the audits, a behavioral intervention was created. The behavioral intervention was created 24 months after the initial educational program implementation. The bedside audit was performed 18 months after the educational program implementation. The behavior implementation included area of best practice principles such as central venous catheter maintenance, hands-on demonstration, annual competencies, lectures, hand washing, and step-by-step pictures regarding the maintenance (Coopersmith et al., 2004). At the end of the study, a sample patient total of 2716 were completed before a behavioral intervention was done. To further elaborate, an additional 72 patients were followed after the behavioral intervention was implemented from November 2001 through February 2002. According to Coopersmith et al. (2004), “patient characteristics and catheter days were similar before and after the behavioral intervention” (p.134).
Instrumentation & Validity The instrumentation consisted of bedside audits and a 20 question multiple pre and post-test. Three team members, without the staff’s knowledge, performed the audits. The audit tool focused on bedside nursing behavior regarding best practice compliance on central venous catheter management. The observer had two choices to circle on the audit sheet, such as yes or no, on best practice compliance. After the initial audits, a behavioral program was created to stress the importance on best practice principles (Coopersmith et al., 2004). Threats to internal validity include history, selection bias, maturation, testing, instrumentation, and mortality (Polit & Beck, 2004). According to LoBiondo-Wood & Haber (2002), “internal validity asks whether the independent variable really made the difference or the change in the dependent variable” (p.194). In this study, history was not a threat to validity, because the researchers demonstrated an increase in best practice compliance and infection rate reduction with the educational program implementation (Coopersmith et al., 2004). To further elaborate, the research for this study exclusively focused on education for all staff ranging from novice to expert experience level. The researchers believe that education on best practice can have a positive impact on changing bedside behavior (Coopersmith et al., 2004). The researchers did not mention selection bias in the study. All of the patients with the same demographics admitted to the Surgical ICU were enrolled in this study during the 39-month time frame. Also, selection bias can be ruled out, because they defined and classified blood stream infection (BSI) before the study was initiated. The researchers BSI definition correlated with National Nosocomial Infections Surveillance (NNIS). Furthermore, there was some nursing turnover, but the new nurses did receive the same education (Coopersmith et al., 2004). The researcher does not mention maturation, instrumentation, or mortality as threats to validity. The observational audit tool, behavioral intervention, and educational modules help control the focus of the research on the importance of best practice principles (Coopersmith et al., 2004). The researcher did an excellent job in all internal validity categories.
Findings
Coopersmith et al. (2004) findings have significant implications for addressing blood stream infection and central venous catheters. Currently, blood stream infection reduction continues to be a national focus in all Intensive Care Units. The research was based on audits that were conducted in a Surgical ICU at Barnes-Jewish Hospital at Washington University School of Medicine. A multidisciplinary team made behavior observation audits without the staff’s knowledge. The audit results showed some non-compliance with best practice principles and hand washing. Coopersmith et al. (2004) reviewed 2716 patients during the 24-month period before the behavior intervention. This result showed 3.4 infections/1000 catheter days compared to 5.8 infections/1000 catheter days from the National Nosocomial Infections Surveillance (NNIS). Furthermore, a behavioral intervention was designed and the information was incorporated into self-study modules. After the education implementation, further audits were preformed. Hand washing, use of maximum sterile precautions, and catheter dressing improved after the education. Subsequent audits showed improvement in the deficient areas of central line insertion and maintenance (Coopersmith et al., 2004). Labeled central line dressing compliance increased from 11% to 21%, maximum sterile barriers compliance increased from 50% to 80%, and hand washing compliance improved from 17% to 30%. According to Coopersmith et al. (2004), “compliance with best practice remained high in principles that were appropriate before the behavior intervention”(p. 134).
Conclusion
The research suggests that the impact of nursing behavior and compliance with hand washing and best practice principles correlate with decrease blood stream infection rates. The positive impact of the knowledge gained through the educational modules are linked with better patient outcomes. Knowledge is powerful for excellent nursing practice; therefore, educating nurses on infection prevention measures is instrumental in improving patient outcomes. Educating staff on best practice has demonstrated lower complication rates and improve patient outcomes. Furthermore, staff education can lead to policy changes and staff compliance on best practice principles.

References
Coopersmith, C. M., Zack, J. E., Ward, M. R., Sona, C. S., Schallom, M. E., Everett, S. J., et al. (2004). The impact of bedside behavior on catheter-related bacteremia in the Intensive Care Unit. Archives of Surgery, 139, 131-136.
Fawcett, J. (2005). Contemporary Nursing Knowledge (2nd ed.). Philadelphia, PA: F.A. Davis.
Lobiondo-Wood, G., & Haber, J. (2002). Nursing Research: Methods, critical appraisal, and utilization (5th ed.). St. Louis, MO: Mosby.
Polit, D. F., & Beck, C. T. (2004). Nursing Research: Principles and Methods (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Warren, D. K., Zack, J. E., Chen, A., Prentice, D., Fraser, V. J., Mayfield, J. L., et al. (2004). The effect of an educational program on the incidence of central venous catheter-associated blood stream infection in a Medical ICU. Clinical Investigations in Critical Care, 126(5), 1612-1618.