NURS 6052 Week 5 Evidence Hierarchy Ranking Example

Ranking Eight Sources on Chlorhexidine Bathing for CLABSI Prevention: Levels of Evidence and the Hard Cases

Student Name

College of Nursing, Walden University

NURS 6052: Essentials of Evidence-Based Practice

Instructor Name

Month Day, Year

Ranking Eight Sources on Chlorhexidine Bathing for CLABSI Prevention: Levels of Evidence and the Hard Cases

Ranked List

Hierarchy used: the seven levels of evidence for intervention questions described by Melnyk and Fineout-Overholt (2023). Within a level, sources are ordered by quality.

1. Buetti et al. (2022), SHEA/IDSA/APIC compendium on preventing CLABSI. Level I. Reason: an evidence-based practice recommendation document whose chlorhexidine bathing recommendation rests on systematic reviews and randomized trials; see hard case A.

2. Frost et al. (2016), a pooled analysis of seventeen ICU studies. Level I, lower edge. Reason: a systematic search and pooled analysis, but of seventeen studies of which seven were cluster-randomized crossover trials and ten were before-and-after studies; see hard case B.

3. Climo et al. (2013), multicenter cluster-randomized crossover trial. Level II. Reason: random allocation of whole units to one cloth type and then the other, across six hospitals; multiple centers strengthen generalizability.

4. Noto et al. (2015), pragmatic cluster-randomized crossover trial. Level II. Reason: random allocation of five ICUs with crossover, a large enrolled population, but a single medical center; ranked below Climo for that reason, not because its result differed.

5. O'Grady et al. (2011), CDC guideline on preventing intravascular catheter-related infections. Level I by the scale's definition, ranked here below the trials. Reason: its bathing recommendation predates the large trials and was graded on weaker evidence than the 2022 compendium; see hard case A.

6. Montecalvo et al. (2012), prospective three-phase before-and-after study in six ICUs. Level III. Reason: an intervention was introduced without random allocation or a concurrent control group; anything else that shifted across the study years, from staffing to line insertion practice, could account for the changes.

7. Musuuza et al. (2017), qualitative descriptive interview study. Level VI. Reason: a single qualitative study; see hard case C.

8. The hospital's own surgical ICU quality improvement report on a chlorhexidine bathing pilot. Not ranked as research; see hard case D.

Hard Case A: Two Guidelines, Two Scales

Guidelines are not research studies, and hierarchies disagree about where they belong. The Melnyk and Fineout-Overholt scale places evidence-based clinical practice guidelines based on systematic reviews of randomized trials at Level I, which is why the 2022 compendium sits at the top: its recommendation for daily chlorhexidine bathing in ICU patients is grounded in the trial evidence reviewed by an expert panel (Buetti et al., 2022). The same document would sit much lower on the Johns Hopkins scale, which places clinical practice guidelines at Level IV as the opinion of nationally recognized expert committees based on scientific evidence (Dang et al., 2022). The level belongs to the scale, not to the document. The 2011 CDC guideline shows the other side of the same point: it qualifies as a guideline, but its bathing recommendation was made before the major trials and rested on less evidence, so its practical weight today is lower than its nominal level (O'Grady et al., 2011).

Hard Case B: A Meta-Analysis of Mixed Designs

Level I is reserved for systematic reviews of randomized controlled trials. Frost et al. (2016) is a rigorous systematic review with a meta-analysis, but ten of the seventeen studies it pooled were before-and-after designs, and the authors used models designed to handle that variation. Its pooled estimate is therefore partly built on weaker designs. It is placed at the lower edge of Level I, with the caveat stated, rather than moved down a level, because its method is systematic and its randomized studies can be examined separately.

Hard Case C: The Qualitative Study

For an intervention question, a single qualitative study sits at Level VI because it cannot estimate an effect. Musuuza et al. (2017) nonetheless stays in the set. Its interviews with nurses and technicians describe why baths are interrupted or skipped, the workload and scheduling barriers, and the organizational supports that helped, which is exactly what the unit will need to know at implementation. A low level for the effect question does not mean low value for the project.

Hard Case D: The Quality Improvement Report

The surgical ICU's report describes a six-month pilot of chlorhexidine bathing, with infection counts before and after and staff comments. It is not research: it was not designed to produce generalizable knowledge, it had no ethics review as research, and it was not peer reviewed. The Melnyk and Fineout-Overholt levels were built to rank research studies and do not have a place for it (Melnyk & Fineout-Overholt, 2023). The Johns Hopkins model would classify it as nonresearch evidence at Level V, organizational experience. It is kept as local context, since it shows that bathing is feasible in this hospital's ICUs and flags the skin irritation complaints that arose, but it does not count toward the strength of the evidence.

The Set Judged as a Whole

Quantity: the set contains two cluster-randomized trials, one meta-analysis, one before-and-after study, two guidelines, and one qualitative study, a reasonable body for a unit-level decision. Consistency: the results are not fully consistent. The meta-analysis and the multicenter trial support a reduction in bloodstream infections with chlorhexidine bathing, while the single-center pragmatic trial found no reduction in its composite infection outcome, in a setting where CLABSI was already rare. Strength: randomized evidence exists, but it is mixed, and the meta-analysis draws heavily on weaker designs. The thinnest spots are direct evidence on CLABSI specifically, since several trials reported bloodstream infections more broadly, and evidence from ICUs with low baseline infection rates like the ones in which the pragmatic trial found no effect. Overall, the evidence supports daily chlorhexidine bathing in adult ICUs, most strongly where baseline infection rates are high, with moderate rather than strong confidence.

References

Buetti, N., Marschall, J., Drees, M., Fakih, M. G., Hadaway, L., Maragakis, L. L., Monsees, E., Novosad, S., O'Grady, N. P., Rupp, M. E., Wolf, J., Yokoe, D., & Mermel, L. A. (2022). Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 update. Infection Control & Hospital Epidemiology, 43(5), 553-569. https://doi.org/10.1017/ice.2022.87

Climo, M. W., Yokoe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A., Weinstein, R. A., Sepkowitz, K. A., Jernigan, J. A., Sanogo, K., & Wong, E. S. (2013). Effect of daily chlorhexidine bathing on hospital-acquired infection. New England Journal of Medicine, 368(6), 533-542. https://doi.org/10.1056/NEJMoa1113849

Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (4th ed.). Sigma Theta Tau International.

Frost, S. A., Alogso, M.-C., Metcalfe, L., Lynch, J. M., Hunt, L., Sanghavi, R., Alexandrou, E., & Hillman, K. M. (2016). Chlorhexidine bathing and health care-associated infections among adult intensive care patients: A systematic review and meta-analysis. Critical Care, 20(1), 379. https://doi.org/10.1186/s13054-016-1553-5

Melnyk, B. M., & Fineout-Overholt, E. (2023). Evidence-based practice in nursing & healthcare: A guide to best practice (5th ed.). Wolters Kluwer.

Montecalvo, M. A., McKenna, D., Yarrish, R., Mack, L., Maguire, G., Haas, J., DeLorenzo, L., Dellarocco, N., Savatteri, B., Rosenthal, A., Watson, A., Spicehandler, D., Shi, Q., Visintainer, P., & Wormser, G. P. (2012). Chlorhexidine bathing to reduce central venous catheter-associated bloodstream infection: Impact and sustainability. The American Journal of Medicine, 125(5), 505-511. https://doi.org/10.1016/j.amjmed.2011.10.032

Musuuza, J. S., Roberts, T. J., Carayon, P., & Safdar, N. (2017). Assessing the sustainability of daily chlorhexidine bathing in the intensive care unit of a Veteran's Hospital by examining nurses' perspectives and experiences. BMC Infectious Diseases, 17, 75. https://doi.org/10.1186/s12879-017-2180-8

Noto, M. J., Domenico, H. J., Byrne, D. W., Talbot, T., Rice, T. W., Bernard, G. R., & Wheeler, A. P. (2015). Chlorhexidine bathing and health care-associated infections: A randomized clinical trial. JAMA, 313(4), 369-378. https://doi.org/10.1001/jama.2014.18400

O'Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., Lipsett, P. A., Masur, H., Mermel, L. A., Pearson, M. L., Raad, I. I., Randolph, A. G., Rupp, M. E., Saint, S., & the Healthcare Infection Control Practices Advisory Committee. (2011). Guidelines for the prevention of intravascular catheter-related infections. Clinical Infectious Diseases, 52(9), e162-e193. https://doi.org/10.1093/cid/cir257