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Evaluation of Clinical Practice Guideline in Family Practice
The rise in the demand for quality healthcare services today has led to increased utilization of nurses in advanced practice. These nurses have shown improvement in the delivery of services, especially in rural areas, and demonstrated comparable effectiveness to that of physicians (Lopes-Junior, 2021),. One of the most important aspects of advanced nursing practice is the delivery of care that is consistent with the clinical practice guidelines and preferences of patients. Clinical practice guidelines are evidence-based statements that are intended to optimize patient care and improve outcomes. These guidelines are used to address common healthcare problems and guide healthcare providers in delivering high-quality, evidence-based care to patients (Buetti et al., 2022). This discussion focuses on the utilization of clinical practice guidelines to manage common healthcare problems by advanced practice nurses.
C922 Emerging Trends and Challenges in 21st Century Nursing
Healthcare Problem
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Central line-associated bloodstream infections (CLABSI) are a serious and potentially fatal issue. They are caused by the insertion of a central line, a long, thin tube that is placed into a large vein to provide access to the bloodstream and occurs when bacteria or other pathogens enter the bloodstream through the line. CLABSI can cause sepsis, a life-threatening infection of the blood, as well as organ failure and death (Buetti et al., 2022). The incidence of CLABSI is increasing due to the increasing use of central lines in healthcare settings, and the challenge for healthcare providers is to reduce the occurrence of these infections. The primary methods of prevention are proper insertion, maintenance, and removal of the central line, as well as infection control practices such as hand hygiene, proper skin preparation, and the use of antiseptics (Centers for Disease Control and Prevention (CDC), 2021). Despite these efforts, CLABSIs remain a significant challenge.
Screening Adults for Unhealthy Alcohol Use in a Primary Healthcare Setting
CLABSIs remain a threat to most hospitalized patients, especially those in the intensive care and medical-surgical units. Recent statistics indicate these infections occur at a rate of 0.87 per 1000 central line days in the United States (Toor et al., 2022). The main cause of CLABSI involves the entry of bacteria and other microorganisms into the lumen of the catheters causing its spread to the bloodstream. Certain populations are observed to be at greater risk of developing CLABSI and these include those receiving prolonged care, immunocompromised patients, and those admitted to intensive care units (Suwannakeeree & Jullmusi, 2021). Apart from these features, certain populations including African Americans, Hispanics, and Native Americans are at a greater risk of getting infected. The implementation of evidence-based guidelines can be the most effective strategy to reduce the risk of CLABIs among the identified populations.
The mortality and morbidity associated with CLABSIs have reduced over the years but still, the infections pose significant challenges to patients. Mortality from CLABSI is significant, ranging from 7-30%, and is associated with longer hospital stays, higher healthcare costs, and an increased risk of long-term disability (Toor et al., 2022). A recent study shows that CLABSI carries a mortality rate of 12%-155 in the United States and has an odds ratio of 2.75 in hospital death. Morbidity from CLABSI involves the aspects of sepsis, endocarditis, and other severe infections that cause long-term damage to organs.
CLABSIs are caused by microorganisms that enter the bloodstream through central lines. There are two types of central lines used in the ICU and other clinical settings. The first category is tunneled catheters that are surgically implanted into the internal jugular, femoral, or subclavian veins (CDC, 2021). The second category involves non-tunneled catheters used for the temporary administration of treatment and nutrition. Regardless of the catheter type used, the pathophysiology of CLABSIs involves the entry of bacteria like staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae into the lumen of the catheter (Buetti et al., 2022). Entry into the bloodstream can be via direct contact, through a breach in the catheter wall, or mechanical trauma to the catheter hub. Once in the bloodstream, the bacteria cause infection which leads to sepsis, shock, and organ failure. The extent of infection is dependent on host factors like the presence of chronic illness, immunosuppressed state, and a long period of hospitalization before catheter insertion.
CLABSI Prevention Practice Guideline
Clinical practice guidelines represent systematically developed statements used to guide healthcare professionals to make appropriate choices during different circumstances. The importance of the guidelines is to reduce variation in care delivery and promote the delivery of high-quality, evidence-based services to patients (CDC, 2021). CLABSI prevention guidelines are available to guide healthcare providers in inserting and maintaining catheters. One of the most frequently used guidelines is the Centers for Disease Control and Prevention (CDC) checklist for CLABSI. This guideline was developed in 2010 and has ever been used to prevent infections in patients in the ICU and other settings.
The CDC released a guideline to help prevent CLABSI in healthcare settings. The guideline is based on evidence-based practices and is designed to help healthcare professionals reduce the risk of CLABSI. This guideline recommends the implementation of a central line bundle that covers different aspects of catheter insertion, maintenance, and removal (CDC, 2021). For instance, the guideline addresses five core elements that include hand hygiene, maximum barrier precautions, the use of chlorhexidine antiseptic, daily review of catheter necessity, and optimal catheter site care. According to this guideline, all healthcare providers accessing the catheter should wash their hands with conventional soap and water (CDC, 2021). Alternatively, it is recommended to use alcohol-based hand rubs before accessing or removing the catheter.
The second category under the CDC recommendation deals with maximum barrier precautions. It is recommended for providers to use sterile gloves, gowns, masks, and caps during the insertion of central venous catheters (CDC, 2021). In addition, providers must use a sterile full-body drape and use a sterile sleeve to protect catheters during insertion. Regarding the aspect of skin preparation, the CDC guideline requires the use of 0.5% chlorhexidine (CDC, 2021). The antiseptic should be used during insertion and dressing to minimize the entry of microorganisms through the skin. An alternative to this antiseptic is a solution containing 70% alcohol.
Another crucial aspect of the CDC guideline is catheter site dressing regimens. To begin with, providers must conduct a daily review of the need for the catheter by the patient. Considering whether to continue or remove the catheter is essential to avoid prolonged catheterization which increases the risk of infection (Suwannakeeree & Jullmusi, 2021). During the dressing of the catheter insertion site, the providers should use sterile gauze or a transparent dressing to cover the site. In some cases where the site is oozing, it is recommended to withhold the dressing until the situation is resolved (CDC, 2021). A key feature of this guideline under dressing is the replacement of the material after 2 days when used for short-term purposes. For those in prolonged need of the central line, the dressing should be done at least every 7 days (CDC, 2021). Lastly, providers should encourage patients to report any changes in the catheter site including discomfort that may indicate infection or detachment from the insertion site.
The CDC guidelines are designed to help healthcare providers to reduce the risk of acquiring CLABSIs and perhaps the management of at-risk populations. I believe these guidelines adequately address the issue of CLABSI by providing knowledge to healthcare providers, patients, and the institutions affected. Firstly, the CDC clinical practice guideline offers education to providers regarding CLABSI prevention and the most effective strategies to minimize the acquisition of infection. Examples include periodic assessment of central venous catheter (CVC) sites and the use of barrier methods (CDC, 2021). For clinicians, the guideline provides knowledge about proper insertion, maintenance, and when to remove the central lines. The CDC guidelines adequately address the problem of CLABSI by ensuring that organizations understand the right measures and equipment to use. For example, the guideline talks about the use of chlorhexidine, surgical hand rubs, and sterile equipment. To patients, the guidelines advise them to be keen and report any changes that may indicate infection.
The CDC guideline on CLABSI prevention is based on current evidence. The evidence-based practices on CLABSI prevention emphasize the use of hand hygiene using recommended antiseptic solutions during catheter insertion (Toor et al., 2022). Of great focus is the use of a checklist like the one provided by the CDC during insertion. A recent study focusing on strategies to prevent CLABSI found that the use of central line insertion practices is crucial to minimizing CLABSI cases in primary care facilities (Toor et al., 2022). In the past five years, the utilization of the CDC CLABSI prevention guideline has been extensively researched and shown improvement in patient outcomes (Suwannakeeree & Jullmusi, 2021). Nurses and other healthcare providers are advised to understand the CDC guideline and recognize ways to implement various strategies to improve patient outcomes.
The CDC CLABSI prevention guideline does not provide adequate information concerning the management of patients with an actual infection. As a prevention guideline, the CDC discusses CLABSI management in the aspects of catheter insertion and routine care. The guideline provides information about the proper selection of catheters and insertion sites for adults and pediatrics requiring care. The main focus of the guideline is on the aspects of hand hygiene, maximum barrier precautions, and catheter site dressing regimens (CDC, 2021). Other important areas of the guideline include systemic antibiotic use and anticoagulant therapy to reduce the risk of CLABI in general patient populations.
The CDC guideline for CLABSI prevention is very effective. The guideline emphasizes the importance of a multidisciplinary approach to prevention, focusing on the implementation of evidence-based practices, including hand hygiene, the use of chlorhexidine, the use of maximal sterile barrier precautions, and the implementation of a catheter bundle (CDC, 2021). Additionally, the guideline guides the monitoring and evaluation of CLABSI prevention programs, as well as recommendations for reporting and surveillance. Studies have shown that implementation of the guideline is associated with a reduction in CLABSI rates (Buetti et al., 2022). The effectiveness of the guideline has also been supported by its widespread adoption in clinical settings and its incorporation into quality improvement initiatives. To assess its effectiveness, it is important to monitor the number of CLABSI events over time and the knowledge of healthcare providers regarding CLABSI prevention.
Analysis of the Guideline
The CDC guideline for CLABSI prevention provides detailed information about infection management and it can be further improved to incorporate other aspects. The current guideline mainly focuses on infection prevention and control, environmental hygiene, cleaning, and device management. I believe other areas require attention like the involvement of patients and families and how technology can be incorporated to prevent CLABSI. Changes in the guidelines should also focus on the implementation of a comprehensive infection prevention program that includes all the necessary elements, such as education and training, quality assurance, and monitoring and evaluation.
If allowed to change this guideline, I will focus on the aspect of patient safety culture and the utilization of new technologies. Regarding the aspect of patient safety, I would recommend that all patients practice hand hygiene using conventional soap and water just like the healthcare providers before accessing the central line (Suwannakeeree & Jullmusi, 2021). Secondly, each institution should have adequate resources to provide adequate education to patients and families about CLABSIs. On matters of technology, research establishes that inadequate processing of laboratory results and poor communication of results contribute to the late identification of CLABSI (Buetti et al., 2022). Additionally, having a CLABSI risk assessment platform in all healthcare facilities can positively contribute to the management of infections. This may include the location of patients with certain demographic characteristics and other risk factors for developing CLABSI.
Changes in the US demographics and healthcare reform can affect the CDC CLABSI prevention guideline in many ways. To begin with, demographic changes in the number of Hispanics and African Americans mean that more people will be at risk of getting CLABSI upon hospitalization (Toor et al., 2022). Demographic changes can also create disparities in healthcare access and the implementation of preventive measures leading to an increase in CLABSI cases. Healthcare reform could also impact the guideline by creating new regulations and standards to ensure equitable access to care and prevention measures.
To increase the likelihood of adopting new or modified clinical practice guidelines it is important to involve key stakeholders. This strategy will ensure that the guideline reflects the needs and preferences of those who will be using it. The second strategy will involve engaging the public who are the key beneficiaries of the clinical practice guidelines. Lastly, education and training can be an important strategy for engaging stakeholders and other interested parties in adopting the developed guidelines.
Evaluation
Determining the effectiveness of revised clinical practice guidelines for CLABSI prevention will utilize various steps. Step 1 will involve the development of a survey to collect feedback from healthcare providers utilizing the revised clinical guideline. Step 2 will involve a literature search to compare the effectiveness of the revised guideline with the current CLABSI prevention guidelines. Information from the literature will give data about the number of patients affected by the infection and how it compares to the new findings. Step 3 will involve an analysis of CLABSI in the healthcare institution including important aspects like the patient length of stay, CLABSI rates, and complications. Step 4 will involve the evaluation of surveys and feedback from key stakeholders like healthcare providers. This step will help to determine confidence levels in the new guidelines and the likelihood of their adoption across institutions.
References
Buetti, N., Marschall, J., Drees, M., Fakih, M. G., Hadaway, L., Maragakis, L. L., Monsees, E., Novosad, S., O’Grady, N. P., Rupp, M. E., Wolf, J., Yokoe, D., & Mermel, L. A. (2022). Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. Infection Control and Hospital Epidemiology, 43(5), 553–569. https://doi.org/10.1017/ice.2022.87
Centers for Disease Control and Prevention. (2021). Infection control: Intravascular catheter-related infection (BSI).
https://www.cdc.gov/infectioncontrol/guidelines/bsi/index.html
Lopes-Júnior, L. C. (2021). Advanced practice nursing and the expansion of the role of nurses in primary health care in the Americas. SAGE Open Nursing, 7, 23779608211019491. https://doi.org/10.1177/23779608211019491
Suwannakeeree, W. ., & Jullmusi, O. (2021). Prevention of central line-associated bloodstream infection. Journal of Nursing and Health Sciences, 15(2), 14–26. https://he01.tci-thaijo.org/index.php/NurseNu/article/view/249830
Toor, H., Farr, S., Savla, P., Kashyap, S., Wang, S., & Miulli, D. E. (2022). Prevalence of central line-associated bloodstream infections (CLABSI) in intensive care and medical-surgical units. Cureus, 14(3), e22809.
https://doi.org/10.7759/cureus.22809
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