Running Head: Research Critique Part 1 1

Research Critique Part 1
CLABSI in the Pediatric Oncology Population
Cathy Frederick
Grand Canyon University
NRS-433V Introduction to Nursing Research
October 11, 2015

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Purpose of the Research
This paper will perform a research critique on a qualitative research study published in the Infection Control and Hospital Epidemiology, March 2013, Vol. 34, No.3. The study was presented with contributions from multiple individuals, Dr. A. Gaur, Dr. D, Bundy, C. Gao, PhD, Dr. E. Werner, Dr. A. Billett, Dr. J. Hord, Dr. J. Siegel, Dr. D. Dickens, C. Winkle, RN., and Dr. M. Miller. The research was to identify the host and organism characteristics of the hospital-acquired condition, central line-associated bloodstream infections (CLABSIs) in pediatric hematology/oncology patients.
Problem Statement CLABSIs increase the risk for increased mortality and morbidity, extended hospital stays, and raises the overall cost of healthcare.
Children’s Hospital Association Hematology-Oncology Quality Transformation Collaborative Project (CHAHQTCP), was a qualitative research project that began on November 1, 2009 and ended July 31, 2011. This project was initiated to identify the contributing factors to blood stream infections (BSI) in pediatric hematology patients. The goal of this research was to reduce CLABSIs by 50%. To be included, the CLABSI needed occur 48 hours after being hospitalized or within 48 hours of discharge. By identifying the organism and the time surrounding the reported symptoms, and by incorporating standardized central venous catheter (CVC) maintenance care bundles with an adherence rate of 90%, the decrease in CLABSIs would be achieved.

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Purpose and Research Questions The research questions for the study were:
What is the contemporary epidemiology of CLABSIs in hospitalized pediatric oncology patients?
Are CLABSIs the result of a primary or secondary infection site? The study accomplished the aim of identifying the organisms resulting in CLABSIs in the pediatric oncology population. The problem of identifying the primary or secondary sources of infection were challenged by the National Healthcare Safety Network (NHSN) guidelines used. In the case of a CLABSI occurring in a patient with pneumonia, or abdominal abscess the CLABSI would not be considered a confirmed BSI due to the preexisting infection. Patients who had identified mucositis, impaired skin integrity, and impaired gut integrity remained as a positive CLABSI and were not excluded due to these conditions. The patient also had to be in the hospital for 48 hours or within 48 hours of discharge with a CVC in place when symptoms occurred.
The occurrences of CLABSIs in pediatric oncology patients and the increased risk for BSI in these patients contributed to the study being undertaken. A CVC is placed to facilitate the number of intravenous medications, nutrition, and blood products needed over an extended period of time. Although a CVC is lifesaving intervention, the increased risk of infection, death, extended hospital stays, and higher cost of healthcare, affect the usefulness of this device. The average cost of a hospital acquired CLABSI is $55,000, this reflects the cost of care but not the effect the CLABSI has on the patient. Sepsis can rapidly

Research Critique Part 1 4 occur requiring fluid resuscitation, extended hospital stay, and damage to internal organs. During the time of this study, 576 CLABSIs were reported in 36 U.S. pediatric oncology clinics. Of the identified CLABSIs, 64% were identified in patients with leukemia, acute myeloid leukemia (AML) accounted for 60% and acute lymphoblastic leukemia (ALL) had 35%.
Literature review
Qualitative research methods were used to summarize host and organism characteristics related to CLABSI events (Gaur. 2013). A single organism was isolated in 88% of the events. Viridans streptococci, which is a gram positive organism, accounted for 23% of the single organism CLABSIs. The viridans group streptococci (VGS) are a heterogeneous group of organisms that can be human commensals, colonizing the gastrointestinal and genitourinary tracts in addition to the oral mucosa (Doern & Burnham. 2010). The presence of this organism in a patient that is immunocompromised can be a causative factor in endocarditis, intra-abdominal infection, and shock. This may be the primary site of infection with translocation from the CVC in line contamination, and/or oral or gut mucosa. The data included in the research was from 1994 to 2013 and focused on CLABSIs in the pediatric oncology patients. Another such study took place in an oncology and stem cell transplant unit of a freestanding, 396-bed quaternary care pediatric hospital. This study gathered the data with many of the same results seen in the study undertaken by the CHAHQTCP. Our objectives were to describe the microbiology and identify risk factors for hospital-onset CLABSI Research Critique Part 1 5 in this patient population (Kelly. 2011). Of the 20 references cited in this study, the results were similar, gram positive organisms such as viridans streptococci were identified as being the number one source of infection. The weakness of the available studies are, that with the current guidelines in place from NHSN, including patients with known mucositis, impaired skin and/or gut integrity, and neutropenia limit the exclusion of a CLABSI when these conditions are present. These guidelines are for sensitivity over specificity, allowing for a CLABSI to be determined when there may have been a large group with preexisting infections that may not have been a true CLABSI.
Perspective in Grounded Theory The use of grounded theory to analyze the patterns and common categories discovered in the qualitative research study performed, determined that pathogen characteristics remained the same. A single organism, gram positive viridans streptococci, was identified in 23% of the reported CLABSIs. The due to the limitation of excluding mucositis, skin breakdown, and/or diarrhea as possible primary sources of infection will continue to have positive CLABSIs reported. Translocation of the organism in these known conditions contribute to a CLABSI.
Summary
The problem, CLABSIs in pediatric oncology patients, was clearly described. A change in the definition of exclusion for a positive CLABSI is needed, as the primary site of infection may not be included on the NHSN guidelines. This change in the reporting from poor specificity to poor sensitivity will allow for the opportunity of reported CLABSIs.
Research Critique Part 1 6 rates with education on meticulous line can be achieved. The need for standardized central line maintenance care bundles to reduce CLABSIs rates by 90% is a priority.

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References
Doern, C. & Burnham, C. (2010) It’s Not Easy Being Green: the Viridans Group Streptococci, with a Focus on Pediatric Clinical Manifestations. Journal of Clinical Microbiology. 2010 Nov; 48(11) 3829-3835.
Gaur, A. H., Bundy, D. G., Gao, C., Werner, E. J., Billett, A. L., Hord, J. D., & ... Miller, M. R. (2013). Surveillance of hospital-acquired central line-associated bloodstream infections in pediatric hematology-oncology patients: lessons learned, challenges ahead. Infection
Control & Hospital Epidemiology, 34(3), 316-320. doi:10.1086/669513
Kelly, M., Conway, M., Wirth, K., Potter-Bynoe, G., Billett, AL., & Sandora, TJ. (2011) Moving CLABSI prevention beyond the intensive care unit: risk factors in pediatric oncology patients. Infect Control Hosp Epidemiol. 2011; 32(11):1079-85 (ISSN: 1559-6834)