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Use of Chlorhexidine to Prevent Ventilator-associated Pneumonia: Research Critique
The critical appraisal of articles is an important aspect in promoting evidence based practice. In nursing care, critical analysis is conducted for three major reasons; to broaden the nursing knowledge, to understand the evidence based practice and to improve nurse practice. During the critical appraisal, the nurse is required to evaluate the study findings, and relate their appropriateness in clinical practice. This helps assure delivery if effective and safety care in hospitalized patients and in intensive care unit (ICU).
In this context, this paper critically appraises the following article; Zhang, T., Tang, S. and Fu, L. (2013). The effectiveness of different concentrations of chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Journal of Clinical Nursing, 23(11-12), pp.1461-1475. doi: 10.1111/jocn.12312. The article’s problem statement, study purpose, research question, literature view and conceptual framework are critiqued.
This article explores the effectiveness of using chlorhexidine to prevent ventilator-associated pneumonia. Ventilator-associated pneumonia (VAP) is pneumonia that develops in people who have medical devices to assist in controlling respirations through tracheostomy and through endotracheal intubation. The risk factors for VAP include reintubation, aspirations, supine positioning, as well as failed subglottic aspirations. However, the most common mechanism for onset of VAP is colonised oropharyngeal secretions. Therefore, reduction in number of the oral microorganisms is important in preventing VAP (Zhang, Tang, and Fu, 2013).
Research indicates that chlorhexidine (CHX) has antimicrobial compound that effectively works against aerobic and anaerobic bacteria. However, the study results of randomised controlled trials (RCTs) findings are inconsistent. Most of the studies have indicated that CHX effectively prevent VAP but Pineda’s research indicates that use of CHX oral decontamination is not significant in reduction of nosocomial pneumonia in patients who had received MV (Pineda et al., 2006).
This indicates that if the use of CHX for oral care in preventing the onset of VAP is still controversial. Therefore, the article explores other published studies (meta-analysis) to determine the efficacy of CHX and to determine the appropriate concentrations as described by RCTs (Zhang et al., 2013).
The significance of the study is derived from the fact that VAP represents the most common nosocomial infection in ventilated patients. It occurs in about 9-27% of intubated patients. VAP is associated with lengthened hospital stay. It is estimated to increase hospital stay by $50,000-57,000 per occurrence. The disease mortality rate is estimated to be 15-45%. Therefore, it is important to establish the most effective strategy to prevent development of VAP in intubated patients (Zhang et al., 2013).
Purpose and Research questions
The author has not clearly stated the purpose of this study, but the purpose is well indicated as the study objectives and aims. The study aim is to determine the effectiveness of chlorhexidine in the prevention of VAP and to evaluate the preferred CHX concentrations for oral decongestants (Zhang et al., 2013).
The study research questions are as follows (Zhang et al., 2013). ;
a) Is CHX effective in reduction and prevention of VAP?
b) What is the preferred CHX concentration that can effectively reduce the rates of VAP pneumonia?
The purpose and research questions are related to the study problem. The qualitative methods are appropriate to answer these questions because it has the capacity to answer inconclusive study questions. This is attributable to the research method ability to identify sources across various types of studies which helps detect biased and unbiased information. Additionally, this method can help stimulate improvements in the data collected in order to optimize care (Zhang et al., 2013).
The literature review is summative but conjoined with the introductory part of the paper. The researchers report the findings of other papers as a narrative. The literature review points out the controversial information on the effectiveness of the CHX and the preferred concentrations. The information provided is current and adequate to establish a logical argument. For instance, the study indicates that patients on mechanical ventilation drugs have their mouth wide open to facilitate the insertion of the intubation tube.
This breaks the balance of the oral cavity and production of saliva, which makes it easy for bacterial colonization. The literature also states that the mechanical process of intubation compromises the natural barrier that exists between the trachea and oropharynx, which facilitates the entry of the bacteria into the patient lungs (Zhang et al., 2013). Therefore, oral hygiene during intubation is important factor in the control of VAP in ICU and hospitalized individuals.
The literature review also summarizes the current knowledge relevant to research purpose and research questions that is, effectiveness of CHX in prevention of VAP and the preferred concentrations of CHX that effectively prevent the development of VAP. The authors have utilized both quantitative and qualitative studies that focus on prevention of VAP. The articles used also includes randomized controlled study on adults above 15 years who are receiving oral care with CHX as compared to placebo and standard care (Zhang et al., 2013).
The author has not indicated the weakness of the studies available. The articles used in development of the literature are current which are not older than 5 years. However, the study also evaluates studies that were published earlier to facilitate development of logical argument of the study (Zhang et al., 2013).
Theoretical Framework/ conceptual
The author has not identified specific perspectives in which the study was established. The theoretical framework is not well described, but the article has applied the classic grounded theory to analyse the secondary data collected (Maltby, 2010). The paper draws its conclusion from 18 research papers. The aim of the paper is to explore the various mechanisms for VAP management to identify the effectiveness of CHX.
According to this article, the implementation of effective oral care measures effectively reduces the incidences of VAP. However, the several randomised controlled trials conclusion on the effectiveness of chlorhexidine is controversial. Using the classical grounded theory, secondary data is explored to check if the use of CHX in different concentration will yield different outcome. Using this framework, the previous pre-framed data and small data set from the previous papers is improved by comparing the information (Zhang et al., 2013).
This article provides information that will help improve the delivery of care especially in hospitalized patients. It is important to critically appraise articles which help in identification of knowledge gaps (Burns & Grove, 2011). The article aims at establishing evidence based practice that prevents the development of VAP. The article concludes that VAP, which is the leading cause of mortality and morbidity in hospitalized patients and in ICU, is effectively managed through oral care. The article indicates that CHX can reduce the incidences of VAP. The preferred concentration identified by practice is 0.12%.
Burns, N., & Grove, S. (2011). Understanding Nursing Research (5th ed.). Elsevier. ISBN-13: 9781437707502
Maltby, J. (2010). Research methods for nursing and healthcare. Harlow, England: Pearson Education.
Pineda, L. A., Saliba, R.G., & El Solh, A. A .(2006). Effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: a meta-analysis. Critical Care 10, R35.in Zang et al., (2013). The effectiveness of different concentrations of chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Journal of Clinical Nursing, 23(11-12), pp.1461-1475
Zhang, T., Tang, S. and Fu, L. (2013). The effectiveness of different concentrations of chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Journal of Clinical Nursing, 23(11-12), pp.1461-1475. Retrieved from http://eds.b.ebscohost.com/eds/detail/detail?sid=9415ccf3-7260-4097-91b5-822ab962dfbd%40sessionmgr106&vid=0&hid=111&bdata=JnNpdGU9ZWRzLWxpdmU%3d#AN=23952970&db=cmedm
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