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Critical Appraisal

Critical Appraisal

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This Research Critique is aimed at bringing out the fully understanding of the research conducted to determine how effective oral decontamination with 2% chlorhexidine solution can be for the preventing ventilator-associated pneumonia (VAP). The paper will be a critical appraisal that will bring out the in-depth analysis of the article written on the research mentioned above. This critical appraisal is not just to be regarded as another aspect of medical statistics. It is this misconception that often leads to overestimating the level of statistical that is required for critical appraisal (Ajetunmobi, 2002).

The research written in the article that was determining the effectiveness of oral decontamination with 2% chlorhexidine solution for preventing ventilator-associated pneumonia is effective, and the quality of research evidence in it is reliable. This critical appraisal provides evidence of understanding of this hypothesis by looking at some of the actions undertaken in the research and analyzing them. Each of the actions is analysed as a topic on its own. The topics include protection of human participants, data collection, data management and analysis, problem statement, and interpretation of findings.

Protection of Human Participants

Patients infected with ventilator-associated pneumonia face a lot of challenges. The infection increases the length in which the patients stay in thehospital, increases the healthcare costs and as well increases the mortality of the patients. In Siriraj Hospital in Bangkok Thailand, the rate of VAP was 14 episodes per a thousand ventilator days whose main causative agent was gram-negative bacilli. Each episode in Siriraj Hospital increased the patient’s days in thehospitalby a mean of 13.2 days(Danchaivijitr S. et al., 2001). This had a great impact on increasing the healthcare cost and the mortality rate.

The normal oral decontamination had been attempted on this patients, but it was not effective. The research therefore on using oral decontamination that contained 2% chlorhexidine solution stood a chance of giving the patients some hope. The Centre for Disease Control and Prevention proposed the use of this method in 2004 in trying to control the disease. The patients used in the research, therefore, stood a chance of benefiting from the research as it was the best option that stood to be taken at the moment. The trials of the decontamination with ahigh concentration of chlorhexidine in 2006 for its effectiveness in preventing VAP only showed areduction of pneumonia in patients who received mechanical ventilation.

The test was conducted only from adults aged from 18 and above. This is patients who could make their own decision on whether they wanted the test trials done on them or not. However, these patients were mostly those patients in the intensive care unit. This was mostly the patients supported by the mechanical ventilation. Such patients might not even have been capable of making any decision. The doctors were the only ones that could decide what would have been right or wrong for the patients. The results of the controlled tests coming out to be positive would have been a great thing for the patients and thus with or without the consent of the patient, the doctors had to do what was right.

The state of the patients was not one that would need them volunteer for the research. The doctors needed to use their professional ability to determine the patients that would be eligible for the tests just as they did. The Ethics Committee on Human Research of the Faculty of Medicine Siriraj Hospital had approved the study. The conductors of the study had therefore been seen by the committee as fit to do the study and thus they were capable of handling the patients properly as expected. The safety of the participating patients was guaranteed.

Data Collection

The research gives the major variables used in the study. The study was conducted starting January 2006 going through to March 2007 at Siriraj Hospital. The hospital is a university tertiary care with 2,300 beds. Patients aged 18 years and older were eligible who were hospitalized in the intensive care unit that had a total of 36 beds. The patients were also from the general medical wards of a total of 240 beds who received mechanical ventilation. Patients who had been enrolled with ammonia and those who had chlorhexidineAllergywere excluded. A total of 207 patients were used forthe study.

Each of the eligible patientswas randomizedto the normal saline group or the chlorhexidine group according to the sex or hospital location. Data was collected by each patient being examined daily for any presence of pneumonia. A sample of theoropharyngeal swabwas taken from each patient after three days and the after seven days and there after every seven days till the patient developed pneumonia or the dotracheal tube was removed. 108 patients for each group were seen to be necessary for determining whether the oral decontamination with 2% chlorhexidine would decrease the VAP rate from 14 to 7 episodes.

Data Management and Analysis

The data collected was analyzed by descriptive statistics,X2statistics, the unpaired Studentt test, and the Mann-Whitney U test as it was deemed appropriate. The analysis of the data was by use of the statistical soft wares that ensured accuracy. A Pvalue of 0.5 or less was statistically considered significant. Randomized control trials were selected from studies that included three recent meta-analyses. The data from the selected studies was reviewed and combined with the data from the present. The RevMan software, version 4.2 was used in analyzing the data and ensuring accuracy. The use of several studies contacted earlier which contributed to the final results of the study ensured elimination of any bias in the study.

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Findings / Interpretation of Findings: Implications for Practice and Future Research

The study had 207 patients enrolled, 102 of the patients were randomized to the chlorhexidine group and the rest 105 to the normal saline group. The demographic characteristics, location, location, diseases and duration of mechanical ventilation of the patients did not differ significantly(Kollef M, Pittet D, Sanchez Garcia M, et al., 2006). The research givesthese findings in a table of results. The results showed that the effectiveness and safety of using a solution with 2% chlorhexidine for oral contamination of VAP 4.9% that is 5 out of 102 in the chlorhexidine group. For the normal saline group, it was 11.4% that is 12 out of 105. VAP was caused by gram-negative bacilli. The chlorhexidine group patients had had less risk of developing VAP as compared to the patients in the normal saline group.

The finding of the study ware a reflection of the reality. Looking at how the research was contacted, the data collected and analyzed, the results and findings of the study are valid. Personally looking and analyzing the results I have great confidence in the results and that the results can be used in handling VAP. The presentation of the findings was clear and logical. The findings as expressed and presented are coherent and reflect the expectations of a good finding regarding the study in question.

The research having presented valid findings regarding the study, the findings can be applied in nursing practice. The findings if applied in the treating VAP as seen in the study can greatly reduce the number of people that get infected with pneumonia. The findings if applied in the field of nursing would reduce the healthcare cost at a great deal as the use of 2% chlorhexidine solution for oral decontamination would reduce the episodes per ventilator days as per the findings. The findings as well have the impact of reducing mortality. Further studies need to be done so as to find a permanent solution to the VAP infection.


The research written in the article that was determining the effectiveness of oral decontamination with 2% chlorhexidine solution for preventing ventilator-associated pneumonia is effective, and the quality of research evidence in it is valid. The findings as presented by the research illustrates the importance having the 2% percent chlorhexidine solution for preventing ventilator-associated pneumonia as it is the best solution so far for the infection. Presentation of the research was up to the expectation of the nursing profession and presented the reality of the ventilator associated pneumonia and its prevention. The whole research and its presentation gives a lot of knowledge that is important for application in the nursing profession. First is the method of carrying out a study and presenting the study and the findings in a coherent manner. The study is presented professionally in a way that any other nursing study can be carried and presented to give a valid message. The study has followed the nursing profession and practices in the study of the ventilator associated pneumonia that is a lesson to be learned. It helps and gives a lot of information regarding the nursing practice concerning VAP.


Ajetunmobi, O. (2001) Making sense of critical appraisal London: Arnold. Centers for Disease Control and Prevention. National Nosocomial Infections Surveillance (NNIS) System report, data summary from January 1992 through June 2004, issued October 2004.Am J Infect Control2004; 32:470-485 Danchaivijitr S, Dhiraputra C, Santiprasitkul S, Judaeng T., (2001) Prevalence and impacts of nosocomial infection in Thailand. Kollef M, Pittet D, Sanchez Garcia M, et al., (2006) A randomized double-blind trial of iseganan. Richards MJ, Edwards JR, Culver DH, Gaynes RP., (1999) Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System.

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