“LeMaster, C. H., Hoffart, N., Chafe, T., Benzer, T., & Schuur, J. D. (2014). Implementing the central venous catheter infection prevention central line bundle in the emergency department: experiences among early adopters. Annals of Emergency Medicine, 63(3). 340-350. doi: 10.1016/j.annemergmed.2013.09.006” Qualitative Research Critique and Ethical Considerations
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Background of Study:
LeMaster et al. (2014) presented the results of a study that was conducted with the intention of identifying the specific barriers and enablers to the adoption of central line bundle in the emergency department. This is based on the awareness that despite being preventable, central line-associated bloodstream infection (CLABSI) are still common in the emergency department where they cause avertable mortality and morbidity. CLABSI is identified as the leading cause of preventable mortality and morbidity in the emergency department reported in 0.16% of the cases that pass through the emergency department. The study identifies central line bundles as the combined use of safety teams, checklist implementation, chlorhexidine, washing hands, and barrier precautions to address CLABSI. The article further concedes that although medical organizations have reduced CLABSI incidences in their facilities through structured approaches, their efforts have achieved less desirable outcomes in the emergency department. This has been blamed on operational barriers that hinder the implementation of central line bundles in the emergency department. Some of the operational barriers include high patient volumes in the emergency department and high acuity, associated use of checklists, need for workflow redesign, and engaged medical personnel. The study was justified that to decrease CLABSI in the emergency department, there was a need to identify the specific barriers and enablers linked with central line bundle use in the emergency department as some of the factors that must be considered for central line bundles to be successfully implemented in the emergency department (LeMaster et al., 2014). In this respect, the study sought improve central line bundles implementation in the emergency department to decrease CLABSI incidence.
Method of Study:
To identify the specific barriers and enablers linked with central line bundle use in the emergency department, the study applied a qualitative research approach. The approach included elements of grounded theory that recruited medical personnel employed in six emergency departments that applied central line bundles. The study recruited participants in two phases. The first phase comprised of 49 participants who include physicians, nurses, and administrators who were subjected to semi-structured interviews. The second phase entailed conducting three focus group discussion sessions that had between six and eight participants. The interviews and focus group discussions collected the participants’ opinions about their experiences with using central line bundles in the emergency department. The transcripts from the interviews and focus group discussions were then subjected to thematic analysis that identified topic commonalities based on the information trends (LeMaster et al., 2014).
The qualitative approach applied in LeMaster et al. (2014) was considered appropriate. That is because it is based on grounded theory, an approach that examines new phenomena from an unknown position to a known position while creating a base for future research. By applying this approach, the study is able to use individual perceptions and experiences to generate theory that would guide future research activities. From this perspective, it is clear that the research is able to explore new themes as they emerge, something that would not have been possible if other research methods had been applied. Besides that, the use of semi-structured questions implies that the interaction with the participants did not rely on fixed set of questions. Instead, the questions could be considered as loose guidelines that allow for new themes to be explored in detail even as they emerged. Also, the approached ensured that the collected primary data could be linked to the secondary data collected from reviewing relevant past publications. Through applying a qualitative approach, the primary and secondary information were turned complementary so that the study easily transitioned from a known position towards an unknown position even as it developed new theories. The secondary information from the literature review already showed that applying central line bundles reduced CLABSI, although this was not true for the emergency department. Through identifying the enablers and barriers to central line bundles use in the emergency department, the study is able to present new theory on how best to reduce CLABSI in the emergency department using central line bundles. The support for qualitative research approaches is also presented in McAlearney and Hefner (2014) and Rajwan (2013) that present new theories about CLABSI prevention. McAlearney and Hefner (2014) notes that although bundles are useful, their success is dependent on whether medical personnel are comprehensively included in the implementation. Rajwan (2013) similarly presents new theory by proposing that bundle development should include the perspective of both patients and medical personnel. Qualitative Research Critique and Ethical Considerations
Results of Study
The study results were presented in terms of the themes that had been identified in the study. Firstly, it identified barriers to central line bundle adoption in the emergency department to include difficulty in infection surveillance and tracking compliance, ambiguity in roles, high acuity and volume in the emergency department, culture, space, staffing, and time constraints. Secondly, it identified the enablers for central line bundle adoption in the emergency department to include champions, infection and compliance surveillance data, empowerment of observers, clear personnel responsibilities and engagement, and workflow redesign. These results are important to emergency department personnel and administrators since it shows them the specific enablers that should be leveraged and barriers that should be addressed to effectively reduce CLABSI incidence to the desired levels in the emergency department. These results can be used as evidence to show that central line bundles can effectively be used in the emergency department to achieve results similar to those reported when bundles are used in other departments (LeMaster et al., 2014). Ethical Considerations
LeMaster et al. (2014) does not indicate whether there were any ethical considerations when the study was conducted. In fact, there is no mention about whether or not the participants provided informed consent to indicate their readiness to participate in the study. Despite the absence of tangible evidence to show that there were ethical considerations in the study, there is no evidence to show that ethics was not considered in the study. Firstly, the study recruited medical professionals whose participation was voluntary. This shows that although they did not provide informed consent, they could withdraw from the study whenever they felt like doing so to imply that a consent form was unnecessary. Secondly, the study proceeded after approval was received from the institutional review board. The approval from the board implies that the researchers had provided ample evidence to show that the participants would be protected from harm and their rights would be protected during the entire course of the study. Finally, the identity of the participants was protected since they were not identified in the article (LeMaster et al., 2014).
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LeMaster et al. (2014) present the results of a study to evaluate how central line bundles can best be applied in the emergency department to reduce CLABSI incidence. It concedes that although central line bundles have been effectively applied in other departments with positive results regarding CLABSI incidence control, the same cannot be said for the emergency department where their results have been limited. Applying a qualitative research approach that recruited participants from the emergency department, the article noted that there were barriers and enablers to the bundles adoption. The barriers include difficulty in infection surveillance and tracking compliance, ambiguity in roles, high acuity and volume in the emergency department, culture, space, staffing, and time constraints. The enablers include champions, infection and compliance surveillance data, empowerment of observers, clear personnel responsibilities and engagement, and workflow redesign. Based on the results, the recommendation is made that the barriers should be addressed and enablers leveraged to improve the results of central line bundle adoption in the emergency department. Qualitative Research Critique and Ethical Considerations
LeMaster, C. H., Hoffart, N., Chafe, T., Benzer, T., & Schuur, J. D. (2014). Implementing the central venous catheter infection prevention central line bundle in the emergency department: experiences among early adopters. Annals of Emergency Medicine, 63(3). 340-350. doi: 10.1016/j.annemergmed.2013.09.006
McAlearney, A. S., & Hefner, J. L. (2014). Facilitating central line–associated bloodstream infection prevention: a qualitative study comparing perspectives of infection control professionals and frontline staff. AJIC: American Journal of Infection Control, 42(Supplement), S216-S222. doi: 10.1016/j.ajic.2014.04.006
Rajwan, Y. G., Barclay, P. W., Lee, T., Sun, I.-F., Passaretti, C., & Lehmann, H. (2013). Visualizing central line-associated blood stream infection (CLABSI) outcome data for decision making by health care consumers and practitioners – an evaluation study. Online Journal of Public Health Informatics, 5(2), 1-18. doi: 10.5210/ojphi.v5i2.4364 Qualitative Research Critique and Ethical Considerations
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