Sie sind auf Seite 1von 9

Running head: CLINICAL QUESTION: ANTIBIOTICS IN CABG PATIENTS

Clinical Question: Antibiotics in CABG Patients


Amy Lewis
Ferris State University

Abstract
Utilizing the most recent evidence-based research from three articles, the author of this paper has
attempted to confirm the necessity to administer appropriate antibiotics to coronary artery bypass
graft (CABG) patients in order to decrease postoperative sternal wound infections. In an attempt
to improve post surgical outcomes for the CABG patient, there has been much research done in
ways to decrease the risk of infections, and following the Surgical Care Improvement Project
(SCIP) initiatives has been one way that has proven to be effective. The purpose of this paper
was to present an issue, and to utilize research articles to support the change in nursing practice
necessary to accomplish the task. The challenge of encouraging nurses to think in terms of
quality and safety education as they change their healthcare practice is also addressed in this
paper.

CLINICAL QUESTION: ANTIBIOTICS IN CABG PATIENTS

Clinical Question: Antibiotics in CABG Patients


In order for nurses to be able to interpret the results and findings of research, they review
evidence-based research to support decisions that are made within their nursing practice.
Clinical decisions should be based on the most accurate, most reliable and up to date research
available within the field of nursing. One method of fundamentally evaluating evidence based
research is to use the method of using a PICO question. PICO stands for patient problem or
population (P), intervention (I), comparison (C), and outcome (O). The purpose of this paper is
to describe what a PICO question is, present one, and then use this method to evaluate
appropriate research to either support or negate the PICO question. For the purposes of this
paper, a limited number of research articles will be reviewed to evaluate the following PICO
question.
Clinical Question
The PICO question that I will be examining in this paper is Does the administration of
preoperative antibiotics in the CABG patient reduce the occurrence of postoperative sternal
wound infections compared to CABG patients who do not receive preoperative antibiotics?
Having worked with open heart patients for over 30 years, post operative sternal wound
infections have been an unfortunate complication that some of these patients are faced with.
Hospital acquired post operative infections can impact patient morbidity, affect their
length of stay and significantly impact the cost of care (Haycock et al, 2005). There are often
organisms that are resistant to specific antibiotic regimens, and many of these types of infections
then become difficult to treat. Having the complication of a deep sternal wound infection can

CLINICAL QUESTION: ANTIBIOTICS IN CABG PATIENTS

prolong an open-heart patients recovery period, if they are able to recover from the infection at
all. Healthcare organizations have pursued many different paths toward avoiding infections in
their patients, including participation in a project called SCIP, which stands for the Surgical Care
Improvement Project.
While there are many facets to SCIP, the one that will be presented in this paper is the
prevention of post-operative infections in the coronary artery bypass graft (CABG) patient.
When there are specific routines followed that have been based on evidence-based research,
patient safety and quality can be improved and enhanced by setting and practicing a specific
standard of care. The administration of preoperative antibiotics, given within one hour of skin
incision, has been show to be an effective strategy for the reduction of this surgical complication.
Methodology of Researching Articles
While performing research for this project has been a challenge, at times it was necessary
to change some of the wording that I used during my search of available research that had been
performed. Searching nursing peer reviewed articles was one of my criteria during my
evaluation of articles used, and making sure that there were nurses involved in the research as
well as the writing of the article was essential. These types of articles would be most appropriate
to the evaluation and changing of nursing practice.
Using the online libraries, through Ferris State University and through Spectrum Health, I
was able to do a literature search using key terms such as sternal wound infections,
prevention of post-operative infections, CABG and open-heart surgery. The specific
search databases that I used were PubMed and CINAHL and these provided me with several
articles each, which were appropriate for this particular PICO question. Changing the wording
of what was used in the searches became necessary at times, and reading the abstracts helped to
narrow down the articles that were then chosen to review. Using search restrictors such as peerreviewed, specifying articles written in the last five years, articles in nursing journals, and those

CLINICAL QUESTION: ANTIBIOTICS IN CABG PATIENTS

written in English helped to eliminate some articles that would not be appropriate for this PICO
question.
Printing out the articles is one way that proved beneficial for me to be able to read them
thoroughly, and then compare and contrast the information provided in them. Finding the
information that is appropriate for nursing practice and the implications that the action of
administration of antibiotics preoperatively has, was important for this project. As a bedside
nurse, the importance of using appropriate literature to influence practice change is essential to
improving patient outcomes, which in turn improves safety. By utilizing the most recent
evidence based practice literature, changes for the improved safety and quality of patient
outcomes remains the goal.
Evaluating these research articles for the level of evidence is important when considering
the research provided and using this to make potential practice changes. Not all research studies
are equal regarding the strength of the evidence presented (Armola et. al., 2009). There have
been several systems that evaluate the levels of evidence and the one that I am most comfortable
using during my evaluation of articles are the levels described by the American Association of
Critical-Care Nurses (AACN).
Discussion of Literature
The first research article reviewed was written by a group of registered nurses employed
by St. Francis Hospital in Columbus, Georgia. The nurses had identified a need to reduce the
incidence of surgical site infections (SSI) in the CABG patient population at their hospital,
specifically in the cardiovascular intensive care unit. Determination was made that the process
of their surgical care team could be improved by stricter adherence to evidence based practice
recommendations and also to building in safeguards to ensure these recommendations are
followed through on (Travis, J. et al, 2009). Implementation of this stricter adherence to SCIP
recommendations involved several departments, including nursing, physicians, and pharmacists.

CLINICAL QUESTION: ANTIBIOTICS IN CABG PATIENTS

This study was a level C, according to AACNs evidence-leveling system, and was a
qualitative study using systematic reviews (Armola et al., 2009). The goal of reducing infections
at the surgical incision site in the CABG population was achieved through implementation of the
SCIP standard of both administration of preoperative antibiotics within one hour of skin incision
and discontinuation of antibiotics within 48 hours after surgery. While there was not data
presented in this article regarding only the use of preoperative antibiotics, there was statistically
significant improvement in the numbers of sternal wound infections when preoperative
antibiotics were used in conjunction with other interventions.
The second research study that was read and evaluated in relation to my PICO question
was one written by nurses employed at Banner Good Samaritan Hospital in Phoenix, Arizona.
The objective of their study described by Haycock et al. (2005) was to decrease the incidence of
sternal wound infections by examining and changing current practices in the preoperative and
postoperative (p. 299) period of those patients who were undergoing open heart surgery, but not
specifically CABG surgeries. This would have included valve replacements, septal defect
repairs, and atrial appendage surgeries. There were five areas of improvement evaluated in this
study, one of which was preoperative antibiotics prophylaxis. The Cochrane-Armitage Test of
Trend study rating system was used for this study (Haycock, 2005).
This study is level C in the AACNs evidence leveling system and retrospectively
reviewed the charts of seven patients who had sternal wound infections postoperatively (Armola,
et al., 2009). They found that while all of these patients had received preoperative antibiotics,
there was varied times and types of antibiotics given (Haycock, 2005). According to this article,
this hospital made several changes at once so the conclusions listed were that the combination of
preoperative antibiotics given within one hour of skin incision, standardized skin preparation,
blood glucose control, post operative wound care management and improved hand hygiene all

CLINICAL QUESTION: ANTIBIOTICS IN CABG PATIENTS

had an impact on decreased post operative sternal wound infections. While there were several
facets of open heart patients care evaluated in this article, there was shown to be a decrease in
sternal wound infections when these initiatives were followed, thus supporting my PICO
question.
The final article that was reviewed for this paper was written about postoperative
infections in several different types of surgery, including CABG operations. The article took into
account many different factors regarding patients undergoing CABG surgery, including
comorbidities, such as age, obesity, diabetes mellitus, hypertension and cardiac index (Anderson,
2014). This was a population-based cohort study, in Olmsted County, Minnesota and was a level
C evidence-level according to the AACNs system (Armola, et al., 2009). This study reported
that even when there was strict adherence to the SCIP protocol of administering prophylactic
antibiotics within an hour of skin incision, there was still a sternal wound infection rate of 2.2%.
The mentioned study was done to look at what additional measures could be performed to
further avoid deep sternal wound infections and evaluated such measures as weight based
antibiotic dosing and re-dosing antibiotics during surgeries longer than three hours (Anderson,
2014). While this article took the measure of preoperative antibiotics to another dimension by
adding weight based dosing in addition to the re-dosing of antibiotics during long surgical
procedures, my PICO question was supported in the way that using appropriate preoperative
antibiotics was shown to decrease postoperative sternal wound infection rates.
Significance to Nursing
The significance to nursing regarding post operative sternal wound infections has many
facets, and includes quality and safety of care, as well as providing the best evidence-based care
available to the patient. Integration of the best available evidence and clinical expertise while
being cognizant of patient values is important. One of the important roles that nurses have is
identifying their current clinical practice and identifying the need for change. This evaluation

CLINICAL QUESTION: ANTIBIOTICS IN CABG PATIENTS

and change to a nurses practice should be done after evaluation of the best and most recent
research available (Haycock, 2005).
Utilizing information from research studies involves using the results from specific
studies that concentrate on a specific clinical issue, and evaluating whether this is the best and
safest practice for our patients (Nieswiadomy, 2012). Quality of nursing care can be greatly
influenced by the nurses ability to identify when there is an issue and then follow the correct
channels to make changes in the institutions nursing care. According to the American Nurses
Association (ANA, 2010), standard nine, the registered nurse utilizes current evidence-based
nursing knowledge, including research findings, to guide practice (p. 51), and the nurse should
be capable of integrating both evidence and research findings into their practice (ANA, 2010).
This is accomplished by applying current evidence-based research findings to initiate change in
practice when necessary for the most up to date and safest care for the patient.
The Quality and Safety Education for Nurses (QSEN) initiative was designed to
incorporate both quality and safety competencies into the education of nurses (Dolansky &
Moore, 2013). Nurses are now challenged to move beyond the application of QSEN
competencies to applying the concepts to both individual patients and families. Additionally,
nurses are challenged to merge this type of systems thinking in both quality and safety education,
as well as into healthcare delivery.
Sternal wound infections can be painful and debilitating for patients and can have a
profound affect on their quality of life. Using improved adherence to recommendations, which
are based evidence-based research and practice can be key in changing nursing practice for the
better (Travis et al., 2009). Communication and the use of improved collaborative efforts
between all of the departments involved in a patients care can help a healthcare system to
perform at a higher level, and be instrumental in improving care of the patient.

CLINICAL QUESTION: ANTIBIOTICS IN CABG PATIENTS

Several methods of ensuring the use of appropriate and appropriately timed antibiotics
were demonstrated in the research articles reviewed. Each facility needs to review and evaluate
which of these methods would be most beneficial and functional for their use and ensure
adherence. Current practice should be evaluated and literature reviewed, which can help to detail
the best practice available. Process teams can then be formed to help to integrate change where
it is needed. The necessity to adhere to healthcare policies within an organization is essential
when choosing to made decisions and change based on scientifically proven evidence.

CLINICAL QUESTION: ANTIBIOTICS IN CABG PATIENTS

References
American Nurses Association. (2010). Nursing scope and standards of
practice. Silver Springs, MD: American Nurses Association.
Anderson, D. J. (2014). Prevention of Surgical Site Infection: Beyond SCIP. AORN Journal,
99(2), 315-319. doi:10.1016/j.aorn.2013.11.007
Armola, R. R., Bourgault, A. M., Halm, M. A., Board, R. M., Bucher, L., Harrington, L., &
Heafey, C. A. (2009). AACN levels of evidence: What's new?. Critical Care Nurse, 29(4),
70-73.
Dolansky, M. A., & Moore, S. M. (2013, September). Quality and safety education for nurses
(QSEN): The key is systems thinking. The Online Journal of Issues in Nursing, 18(3).
doi:10.3912/OJIN.Vol18No03Man01
Haycock, C., Laser, C., Keuth, J., Montefour, K., Wilson, M., Austin, K., & Coulen, C. (2005).
Implementing evidence-based practice findings to decrease postoperative sternal wound
infections following open heart surgery. Journal of Cardiovascular Nursing, 20(5), 299305.
Nieswiadomy, R. M. (2012). Foundations of nursing research (6th ed.). Boston: Pearson.
Travis, J., Carr, J. B., Saylor, D., King, A., Bence, W., Key, S., & Kinney, C. (2009). Coronary
artery bypass graft surgery: Surgical site infection prevention. Journal for Healthcare
Quality, 31(4), 16-23.

Das könnte Ihnen auch gefallen