NUR 590 Benchmark Evidence-Based Practice Project Proposal Final Paper

Benchmark – Evidence-Based Practice Project Proposal Final Paper Example

Problem Statement

In recent years, insertion of a central line has been a common procedure for both outpatient and inpatient settings. The central lines are used for renal replacement therapy, administration of medication, monitoring of hemodynamic state, and nutritional support, among others (Huybrechts et al., 2021). Likewise, patients in the intensive care unit (ICU) are in critical condition and require central lines for the aforementioned purposes. Therefore, central line insertion is a common procedure for ICU patients, and a correct insertion procedure must be adhered to.

Unfortunately, the central lines act as a passage of infective agents, including bacteria, viruses, and fungi. These infections are termed central-line-associated bloodstream infections (CLABSI). This is attributed to either wrong insertion procedures, poor maintenance of catheters, and failure to monitor the central lines. Once an infective agent accesses the body, it spreads through the bloodstream to cause severe systemic infection. CLABSI leads to an increased hospital stay that increases the cost of care, resulting in reduced patient outcomes.

Notably, up to 41000 new CLABSI infections are reported in the United States, with an estimated annual expenditure of 2.68 billion dollars (Huybrechts et al., 2021).  Furthermore, despite the achievement in treating CLABSI with antibiotics, there has been a recent increase in antibiotic resistance. As a result, most healthcare institutions focus on preventive measures to reduce the rate of CLABSI and improve patient outcomes.

The proposed preventive measures include; aseptic insertion of a central catheter; proper maintenance by either dressing, cleaning, or bathing; appropriate hand hygiene, and removal of unnecessary catheters when not in use (Karagiannidou et al., 2019). Chlorhexidine has been used for bathing the central line leading to a reduced CLABSI rate. Most healthcare providers understand the importance of chlorohexidine; however, few adhere to the guidelines.

Therefore, this evidence-based proposal will discuss the effectiveness of chlorhexidine compared to normal saline in reducing the rates of CLABSI. The project aims at increasing knowledge among healthcare providers to adhere to daily bathing of central line with chlorohexidine. The PICOT question is:  In patients admitted to ICU with a central line catheter (P), how does the use of chlorhexidine (I) compared with flushing the central line using normal saline (C) lead to the reduced central line-associated bloodstream infection (O) over six months (T)?

Literature Review

CLABSI is defined as any infection that develops within 48 hours of central line insertion or after catheter removal and cannot be related to other factors apart from the central line. It is the most common form of hospital-acquired infection (HAI) among patients admitted to the ICU. According to Haddadin et al. (2022), the annual incidence of CLABSI in the US is above 41000 cases, estimated as 0.8% per 1000 central line days. The same author states that the global incidence is estimated at 3.73% per 1000 central line days.

The increasing incidences lead to an increased hospital stay, reduced quality of life, increased mortality and morbidity, and increased cost of care. The estimated annual cost of care due to CLABSI has recently increased from 670 million dollars to 2.68 billion dollars (Karagiannidou et al., 2019). The increased expenditure strains the healthcare budget with an increased cost of care. However, untreated cases lead to mortality and morbidity. The global mortality rate is estimated at 12-25% (Payne et al., 2018). This rate is expected to rise if preventive measures are not adhered to.

Several microorganisms are known causes of CLABSI. They range from bacteria, viruses and fungi, with the commonest cause being bacteria. Staphylococci, including Staphylococci aureus and coagulase-negative staphylococci, are the leading causes of CLABSI. Enterococci, aerobic gram-negative bacilli, and yeast follow in that order (Haddadin et al., 2022). Notably, infections of the hemodialysis catheter are caused disproportionately by staphylococcus aureus. On the other hand, infections among patients with cancer are caused mainly by gram-negative bacilli. Yeast and gram-negative bacilli are common in femoral veins catheters, while candida infections are common in central lines for parenteral nutrition.  

Various risk factors exist that increase the likelihood of a certain population to develop CLABSI, unlike others. These factors are related to either patient, healthcare providers, and catheter-related.  CLABSI rate is increased among patients who are either immunocompromised, those with severe illness, granulocytopenia, or those with existing distant infections (Zerr et al.2020). Likewise, failure to adhere to aseptic procedures during central line insertion and catheter maintenance while in place increases the risks of disease.

In addition, failure to monitor catheters and prolonged use of central line catheters increase the risk of infection. Furthermore, the site of the central line also determines the risk of infection. The rate of infection increases in the following sites in descending manner; femoral catheters more than the internal jugular vein and lowest in the subclavian vein catheters. Preventive measures are required to reduce the rate of CLABSI while eliminating risks.

Prevention of CLABSI requires the use of evidence-based practice (EBP). These practices have been used in various settings with a resultant decrease in the CLABSI rate. According to Urbancic et al. (2018), these measures include correct insertion practice, good maintenance, and monitoring for the need for a catheter. When inserting a catheter, aseptic techniques should be used. This requires insertion by trained personnel, adhering to hand hygiene, preparation of insertion site skin with 0.5% chlorhexidine, and using sterile barrier precautions during insertion.

Maintenance of the central line requires bathing and dressing of the central line, preferably with Chlorhexidine, to reduce infection rate and educate both patients, healthcare providers, and relatives about the importance of daily bathing and the technique of bathing. Finally, monitoring of the central line should be done by healthcare providers.

The caregivers should assess the need for central lines in every patient and promptly remove those not needed by the patients. Consequently, prolonged stay of the central line increases the likelihood of new CLABSI. None of the preventive measures of CLABSI is superior to either. However, the use of chlorhexidine has been used by various centers with a positive result achieved.

Chlorhexidine gluconate is a disinfectant and antiseptic agent with bactericidal properties against antimicrobial agents, including aerobic and anaerobic agents. When applied to the skin, Chlorhexidine prevents skin colonization with germs and disease-causing microorganisms, reducing the infection rate (Payne et al., 2018). It is effective against broad-spectrum bacterium and has a fast onset of action after application. Notably, various studies have been done in multiple settings to assess the effectiveness of chlorhexidine in preventing CLABSI.

Several authors and researchers have done studies involving the use of Chlorhexidine to support its effectiveness and citing reasons why it should be used in clinical practice. To begin with, a study was done by Reynolds et al. (2021) that sought to evaluate the effectiveness of implementing the practice of daily bathing with chlorohexidine in combination with a multifaceted program to reduce CLABSI. A qualitative-clustered randomized study was done.

The involved nurses were given training regarding the proper technique of bathing central lines with chlorohexidine, and they were encouraged to adhere to daily bathing. The champion nurses then observed nurses as they bathed central lines. Findings from the study indicated a 24% reduction in the CLABSI rate among patients bathed daily. Likewise, another study conducted by Urbancic et al. (2018) in the Australian tertiary ICU showed a decrease in methicillin-resistant staphylococcus aureus (MRSA) and minimal CLABSI reduction.

Yet, in another study by Zerr et al. (2020), participants were grouped into cases and controls among pediatric patients undergoing hematopoietic stem cell transplantation. The cases or study groups received daily bathing with Chlorhexidine, unlike the controls who were not bathed. Blood cultures were collected from the groups, and results were compared. The findings revealed an increased rate of CLABSI among the controls compared to the study group.

Similarly, Giri et al. (2021) did another study at Duke University medical center. They aimed at ascertaining the relevance of using chlorohexidine for allogeneic transplant patients. The results showed a decrease in CLABSI rate among the study group by 15.6%. These two studies are relevant in ensuring adherence to daily bathing is mandatory (Giri et al., 2021).  

Furthermore, in a prospective crossover study by Lowe et al. (2017), the researchers aimed at comparing the effectiveness between soap and chlorohexidine in reducing CLABSI. While the study group received daily bathing with chlorhexidine, the controls were bathed with non-medicated water and soap. After eight months of follow-up of the patients and comparison of laboratory culture, the study group had a 55% reduction in the rate of CLABSI. On the other hand, the control group had a reduced rate of 36%.

The reduced CLABSI leads to improved patient outcomes and a reduction in the cost of care. Nonetheless, it is estimated that effective preventive measures can save healthcare from losses. For instance, according to Reagan et al. (2019), proper use of chlorohexidine to bathe the central line leads to reduced HAI with resultant decreased cost of care. The same study revealed that up to $815,301 was saved. Therefore, reduction of the healthcare burden requires proper use of preventive measures.

Organizational Culture and Readiness.

Assessment of the organizational culture and readiness is an essential element before implementing a project. Organizational readiness assesses the commitment and the willingness of members of an organization to accept and implement change within an organization. In centers where the readiness is high, the implementation of the project will also be possible. This is because members will be ready to use their resources, committing to ensure that change is achieved. In addition, members will likely cooperate, initiate change, and exert persistence resulting in effective implementation of the evidence-based project (EBP). Therefore, before implementing this project, I assessed Houston`s Methodist culture and readiness.

Like other best healthcare providers in the US and globally, Houston Methodist has a culture of incorporating EBP into the care of patients while improving interdisciplinary collaboration. The administration hires and retains healthcare providers with advanced skills and knowledge to provide cost-effective care while improving patient outcomes. Furthermore, improved interprofessional collaboration through enhanced communication and consultation improves patient care. Therefore, guided by the advanced culture and eagerness to improve, there is a need for periodic knowledge advancement regarding current issues and coming up with better strategies to enhance care while improving patient satisfaction.

In addition, the leadership of the facility is also commendable. Decentralized leadership of the organization involves employers in daily activities to ensure that patients receive the best care. As a result, Staff members are involved in various researches to come up with new innovative techniques that improve patient care. According to Puchalski Ritchie & Straus (2019), leadership that appreciates the contribution of other employers is likely to succeed because every member will be dedicated with improved satisfaction and are likely to offer positive contributions.  Furthermore, the organization is guided by Christian principles and teachings that emphasize protecting human life. This culture encourages members to provide quality care while improving patient outcomes and their quality of life.

Apart from good leadership, the organization is guided by its mission, values, and beliefs. The organization’s mission states its commitment to provide high-quality, cost-effective health care that delivers the best value to the people they serve in a spiritual environment of caring in association with internationally recognized teaching and research. Best value and quality care can be achieved by implementing evidence-based practice (EBP). EBP aims at improving clinical decision-making while ensuring that best practice is provided to patients.  Guided by the mission, the organization is likely to accept the implementation of an EBP process that improves patient care, improves the quality of care, enhances the patients` experience, reduces the burden of care through cost reduction, and reduces mortality rate.

The beliefs of Houston Methodist are grounded on Christian teachings as guided by the Texas Annual Conference of the United Methodist Church. It strives to provide quality healthcare services. The organization believes that God provides life and can heal humans through the actions, lives, and words of others. As a result, everyone is considered sacred and should be treated with utmost care and love. This belief makes it relevant to implement an EBP that will improve the quality of care.

In addition, the organizational values also dictate its commitment to quality care. The guiding values include integrity, compassion, accountability, respect, and excellence. The organization strives for excellence by incorporating EBP and retaining highly skilled healthcare providers who provide the best care with integrity and compassion. Furthermore, interprofessional collaboration enhances the quality of care through improved communication. The use of the TeamSTEPPS assessment tool further affirmed the findings of the organizational culture ad readiness for change.

Team Strategy and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is a proven tool for assessing the level of organizational readiness for change. The tool assesses both the weaknesses and strengths of an organization while determining the skills, attitude, and knowledge towards change (Payne et al., 2018). Using the tool, it is possible to evaluate various parameters, including identified need, readiness about time, resources, and personnel, as well as change sustainability through review and measurement.

Measuring motivation and willingness to embrace change are also part of organizational preparedness. According to the evaluation instrument, Houston Methodist is ready to undertake change thanks to well-organized leadership and a strong organizational culture shaped by the mission, beliefs, and values. Furthermore, the company has a high level of team spirit, mutual support, and information flow, all of which contribute to change preparedness and change implementation.

Furthermore, Houston Methodist has various strengths, including but not limited to the following: encouraging and supporting research, innovation, improved interpersonal teamwork, resource availability, effective leadership, a strong stakeholder relationship, and skilled specialists dedicated to providing personalized patient-centered care. Most of the experienced people in the organization will be part of the stakeholders for this project.

Stakeholders will be required to take an active part in ensuring that the healthcare providers well understand the project to enhance its implementation. Knowledge will be guided towards training other nurses and encouraging them to adhere to bathe central lines with chlorohexidine. Stakeholders will include senior nurses in the ICU, nurse managers, informaticians, and physicians. Senior nurses will form part of champion nurses who will actively educate others through active demonstrations and videos about effective bathing procedures for central lines.

The correct bathing procedure requires observing hand hygiene and using a washcloth infused with chlorohexidine. They will also monitor the nurses as they take part in bathing patients. On the other hand, physicians will be involved in demonstrating the correct insertion technique for central lines while enlightening about symptoms of infections. The earliest sign of CLABSI is temperature abnormalities, either high or low. Finally, nursing informatics will monitor new incidences of infection and report data on the same.

Change Model or Frameworks

Implementation of EBP requires the adoption of an appropriate change model or framework. These frameworks or models will help quickly incorporate various research findings into an EBP to improve healthcare delivery and decision-making (van der Steen et al., 2019). Furthermore, the change model will guide the decision regarding data analysis, interpretation, and research perception. As a result, an appropriate change model must be chosen to ensure the project’s success.

Adopting the wrong model may hinder the implementation of an EBP and increase error incidences. These errors develop due to skewing in the proposed process while deviating to processes aided by personal interests (van der Steen et al., 2019). These interests cause bias. Bias can either be confounding, information-related, or selection bias. Furthermore, bias will likely cause errors that may impair the achievement of the research objectives. Therefore, various models exist, as discussed hereafter.

Various models were listed for consideration in this project to enhance the implementation of the EBP. They include the John Hopkins nursing EBP model, Lowa Model for EBP to promote quality care, advancing research and clinical practice through the close collaboration model (ARCC), and the promoting action on research implementation in health services (PARIHS) framework (Huybrechts et al., 2021). These models have been tried in various settings resulting in remarkable results. However, for this project, the ARCC model was chosen.

The ARCC model adopts the use of mentors to help implement the EBP project in a step-wise manner. Mentors are chosen from the existing team members. However, they are provided with further roles making them superior. Furthermore, they are directly involved with the organization’s daily activities and occasionally communicate with other members regarding the EBP project. They also improve organizational belief towards an EBP aided by the amount of knowledge and skills they depict during the implementation process.

Notably, previous trials using the model resulted in improved patient outcomes and job satisfaction due to reduced burnout. Similarly, I aspire to improve patient outcomes while advancing the quality of care and reducing the rates of CLABSI through bathing central lines with chlorohexidine. In addition, I believe that integrating nurse mentors will positively influence the other nurses to adopt the proposed practice. However, there is a need to adhere to all steps of the model to achieve positive outcomes.

The ARCC model has five major steps that describe the stepwise implementation process. These steps include; assessment of organizational culture and readiness; identification of barriers and strengths; identification and development of EBP mentors; implementation of the EBP, and outcomes evaluation (Huybrechts et al., 2021). Following these steps leads to the project’s success and improves healthcare services.

To begin with, assessment of the organizational culture and readiness is a vital part of the model. This is necessary to determine the preparedness of the organization for change. In this stage, various parameters are required for implementation, including personnel, time, resources, attitude, existing policies, and willingness to adopt change are assessed. Furthermore, both organizational strengths and weaknesses are identified in this stage.

In this project, I chose to use the TeamSTEPPS assessment tool for readiness evaluation. The tool identified various strengths and weaknesses. Decentralized leadership, team spirit, interdisciplinary collaboration, availability of resources, and willingness of the organizational members to accept changes were the identified strengths. In addition, the organizational mission, beliefs, and values favor the need for change and enhance implementation of the EBP.  Therefore, Houston Methodist has all that it takes to implement change.

Identifying facilitators and barriers to implementation is the second step of the model. Facilitators of implementation form the basis under which the whole process will be built, while barriers offer an opportunity for identifying better innovative ways. The anticipated barriers for implementation include limited time, inadequate skills, negative attitude towards change, limited supply from the administration, limited mentors, and increased theoretical knowledge with limited practical knowledge on carrying out research. These barriers may make it hard to implement change if they are not addressed and dealt with appropriately. On the other hand, facilitators include increased teamwork, interprofessional caregiving, ethical approval of the project, and the presence of EBP policies.

The next step of the model is the mentors’ identification and establishment. Mentors are essential for both educational and motivational factors. As educators, mentors will train other nurses using demonstrations on how to bathe lines effectively. On the other hand, their presence will improve the beliefs and confidence of other nurses regarding the EBP process and hence will likely support the process. For this project, mentors will be picked among the clinical team. Thereafter, special training will be offered through meetings, simulations, demonstrations, tutorials, and workshops to increase EBP knowledge and skills. With better skills and expertise, they will provide excellent training to enhance project implementation.

The evidence is then put into effect in the fourth stage. The implementation guarantees that the most up-to-date clinical knowledge is integrated into the clinical perspective to make informed patient care decisions (Yoo et al., 2019). Under the supervision of EBP mentors, nurses will participate in implementing the EBP practice. Research findings, the clinical skills of the attending healthcare practitioners, patient preference, as well as values and ethics, will all influence the practice. In this study, all ICU nurses will be trained in safe central line bathing and urged to bathe central lines regularly to lower CLABSI rates. The correct bathing process involves using Chlorhexidine bathed washcloths to clean skin around the central line to kill germs and prevent infections.

The fifth and last step is to evaluate the results of the practice adjustment. Project evaluation is relevant in assessing the success made compared to the objectives. Furthermore, it is necessary to establish the project’s relevance and the level of achievement in terms of efficiency, impact, effectiveness, project sustainability, and objectives attainment (Melnyk et al., 2017). Furthermore, review ensures that limited resources be used wisely to maximize impact. To improve an EBP, adjustments are performed during the evaluation.

These adjustments aim to fill the gaps identified in the whole process while improving the outlook of the project. Hence, in this project, the project’s expected outcomes include improved patient outcomes, enhanced patient and caregivers’ satisfaction, reduction in the cost of care, reduced readmission rate, improved cohesion, and patient turnover will be paramount during evaluation. Improved patient outcomes are projected due to the high-quality care provided guided by EBP knowledge and skills.   

Implementation Plan

The actualization of the project ideas into practice is dependent on the implementation plan.  The implemented EBP aims to improve knowledge and decision-making to improve patient outcomes. Having a clear implementation plan will enhance the actualization of the project`s ideas into reality, where poor planning is likely to inhibit the integration of the project into practice. Therefore, for effective implementation, it is paramount to have a clear strategy of activities including stakeholders, setting, time, management of barriers and facilitators, resources, cost, and data collection plan.

The project will be implemented in the ICU. ICU is chosen because it receives several patients with reversible life-threatening conditions who require close monitoring and stabilization. As a result, patients will receive life-saving procedures such as central lines. These lines, in turn, act as conduits for germs that cause infection (McDougle et al., 2020).

The conditions are expensive to treat and negatively impact a patient`s life and probably lead to death. Therefore, the project will require efforts from every healthcare giver in the ICU settings for its success. As a result, the ICU team will be the major stakeholders for the project. EBP mentors will offer training involving the use of chlorhexidine-soaked washcloths to wipe the skin around the central lines to prevent germ infestation.

Nonetheless, patients too will be involved in the project. Application of the prospective cohort study will require grouping patients. These groups will either be study groups or controls. Either group will sign a consent form to belong to the study and will be free to live the study anytime without objections. Study groups will receive daily bathing of central line with Chlorhexidine, while the controls will receive normal saline. Comparisons between the two groups will be made to determine the incidence rate among the two groups.

Yet another component of implementation is time management. Implementation of the project will require a minimum of ten weeks, with every activity given a stipulated time. The stakeholders of the project will be identified in week one. The stakeholders will be required to ensure the project’s contents are shared among healthcare providers. Each individual will be given specific roles with instructions on how to accomplish them. This will enhance knowledge and facilitate cooperation leading to implementation.

Resource identification will be happening in the second week. Training of staff will be accomplished in the third week. Training will involve tutorials, demonstrations, and webinars to improve skills and knowledge about the project. From week four to the ninth week, the project will be implemented into practice. Nurses will be observed as they undertake the process, while any concerns raised will be addressed in this period. In week ten, modifications will be made in areas of concern to improve the EBP. Upon implementation, data will be collected to ascertain the project’s feasibility.

The project will be deemed feasible if its outcomes outweigh its cost. As a result, data will be collected to determine if there is a decrease in the rate of CLABSI. Questionnaires, surveys, and medical data from the laboratory will provide the required data. The data will be grouped, tested using the chi-square test, and analyzed by the Statistical Package for the Social Science (SPSS). Thereafter, an auditing tool will be used to compare the project’s outcomes versus the previous data to determine any change achieved.

Finally, identification of barriers and addressing them must be considered. The potential barriers include limited time, insufficient EBP mentors, and resistance from some members. As a result, coming up with a clear implementation can help ensure that every activity is carried out within the stipulated time to avoid time limitations. Mobilizing EBP mentors while explaining the importance and objectives of the plan in improving the quality of care will attract many mentors who will be involved in project implementation (McDougle et al., 2020). The EBP mentors will, in turn, transfer the EBP knowledge to other nurses to help in reducing resistance and encouraging them to participate in the project.

Evaluation Plan

The final part of the project is the evaluation after implementation. Evaluation is vital in identifying any gaps and the success of the project. Therefore, any gaps can be addressed in this phase with various adjustments to perfect the project. Outcomes of the project will also be evaluated. For instance, in this project, I expect improved patient outcomes with reduced CLABSI rates like other studies done before. Likewise, according to Arunga et al.(2021), the correct implementation of daily bathing with chlorhexidine is intended to reduce the CLABSI  rate while improving outcomes, enhancing the quality of care, reducing mortality and morbidity, and reducing the cost of care. However, measurement of these outcomes is essential.

The project’s expected outcomes will be improved quality of care and adherence to the bathing process by nurses. Quality of care will be measured in terms of patient satisfaction, patient turnover, reduction in rehospitalization, and prompt recovery without complications. When patients and relatives are contented with the services, they will, in turn, encourage others to seek the same services, which increase patient turnover, improve income return, and attract more profit that can be used to improve other sectors of patient care (Frost et al., 2018).

On the other hand, adherence to daily bathing will be measured in terms of nursing attitude and acceptance of the project. Nurses with a positive attitude who understand the importance of the project will own patients and do daily bathing while encouraging others to do the same. As a result, the infection rate will reduce, thus limiting judicious use of antibiotics with a resultant decrease in resistance to antibiotics.

Furthermore, the outcomes observed from this project will not only impact one organization but also the neighboring institutions. This is because nurses will share the knowledge with others to improve care. Also, continuous education will be provided to maintain and extend it to other facilities. Finally, a contingency plan is necessary in case the initial plan fails.

 I am confident that the steps I have taken in this project will produce the desired results. However, if the predicted results are not met, I will be forced to re-evaluate the entire procedure. Assessing the availability of resources and employees used throughout the process and identifying deficiencies that could have led to deviations from the intended results would be part of the process review. In addition, I’ll get more information about the implementation process from the champion nurses, as well as their perspectives on the evidence-based project.

Furthermore, I will strengthen my tactics for training nurses and encouraging them to follow the process. This can be achieved by carrying out more demonstrations, encouraging small groups participation, and installing reminders in the ICU. These reminders can be in the form of charts and reminder notes to help nurses adhere to the practice. Finally, if none of the interventions provide the desired effects, I will consider restarting the entire process. More strategies, however, are required to address the gaps.

References

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