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An Investigation into the use of cord treatments on the newborns umbilical cord and the reduction of infection.

A LITERATURE REVIEW.

Kathrine Hill Student Health Visitor.

Bolton University. 2014.

Word count: 3720.

An investigation into the use of cord treatments on the new-borns umbilical cord and the reduction of infection. A Literature Review.

INTRODUCTION.
The purpose of this literature review is to examine the evidence surrounding umbilical cord care in the new-born and what part the use of topical treatments play (if any) in the reduction of infection to the new-born infant.
The umbilical cord is a unique tissue consisting of two arteries and one vein. Wharton’s jelly surrounds the vessels. During pregnancy the umbilical cord assists the placenta by transporting nutrients and waste products to and from the fetus. (Fraser, M. et al 2009). Following delivery of the neonate the cord goes through a process were it dries out, hardens and turns black. The area goes through a process of colonization due to non-pathogenic organisms that pass from mum to baby via skin to skin contact following delivery. The umbilical vessels remain patent for several days following birth and are a susceptible site for infection. Potentially harmful organisms can be spread by cross infection, often caused by poor hand washing techniques of Healthcare workers and the infant’s carers. (Davies, S. 2008).
The World Health Organisation (WHO) reports each year one third of neonatal deaths worldwide (1.5 Million) are due to infection, many of which begin as umbilical cord infection. (Cappuro, H. 2004). Current guidelines for umbilical cord care differ enormously from country to country and establishment to establishment, and most of the current literature surrounding umbilical cord practices indicates practice is based on historical assumptions rather than research evidence. (Tammy, P et al 2004). Documented historical practice of cord care includes coins, plant extracts, raisins, olive oil, coconut oil and colostrum. (Perrone, S et al 2012 and Karumbi et al 2013). Methods currently used for umbilical cord care include triple dye, alcohol, antibiotic ointments/powders, betadine, soap and water and no treatments at all. (Tammy, P. et al 2004).
Following the findings of a COCHRANE review by Zupan and colleagues the WHO made recommendations that include aseptic techniques involving health professionals and hand washing. The use of sharp sterile instruments to cut the cord at birth. Leaving the stump 2-3cms long and placing it outside the nappy area to promote drying. (Perrone, S. et al 2012). However these findings apply primarily to high income countries and hospital settings and so pose the question about treatment in poor income countries and community settings. Current guidelines from the National Institute of Clinical Excellence (NICE 2006) apply to practice undertaken by Health Professionals in the United Kingdom (UK), and have implemented the recommendations from the WHO with regards to dry cord care in the new-born. However with the ever changing climate, increasing poverty and more family’s living below the bread line in the UK, Health Professionals and in particular Health Visitors, will encounter family’s living in unhygienic conditions and are in an optimum position to educate and implement practices that may help reduce infection in their children. Health Visitors need to offer help and advice based on Evidence Based Practice (EBM). With reference to this, the PICO process was applied to formulate a question, thus highlighting the need for this literature review. (PICO 2008).

METHODS.
Aveyard (2010) defines a literature review as “a comprehensive study and interpretation of literature that relates to a particular topic.” For Health Visitors there is an increasing importance related to Evidence Based Practice (EBM) and its relevance in everyday practice. Health Visitors have a duty of care to be up to date with research and development in their field of work, as stipulated by their Governing Body The Nursing and Midwifery Council. (NMC 2010). Literature reviews bring together evidence, systematically review them and bring together the results so they can be viewed as a whole. Aveyard (2010).
A systematic review of literature was performed to identify the existing knowledge base of current practice surrounding umbilical cord care. A search of 5 databases, Pro Quest, Scopus, CINAHL, Cochrane and Medline were undertaken. These databases were specifically chosen as their contents include abstracts, indexes and evidence that can help to inform and develop practice for Health Professionals. The search was commenced using the word “umbilical cord”. This produced a vast amount of literature, so the words “cord care”, “new-born”, and “cord powder”, were introduced to the search. These words also produced a mass of literature some relevant and some not. Due to time restrictions the search was refined and an inclusion and exclusion criteria was applied to the literature search. (table 1).

Table 1. INCLUSION CRITERIA | REASON FOR INCLUSION. | EXCLUSION CRITERIA | REASON FOR EXCLUSION | Literature from 2000-2014. | Relevant and up to date. | Literature before 2000. | Dated Literature. | Abstract relevant to question posed. | Identify relevant papers. | Preterm Infants. | Nursed differently from term baby’s, encounter more interventions. | Term infants. | Relevant to practice. | Literature not readily available. | Time constraints. | English Language papers. | Unable to translate other papers due to time constraints. | | |
The initial search using the key word “umbilical cord” highlighted 1427 papers in CINAHL, 848 in Cochrane, 745 in Medline, 390 in Pro Quest and 17,672 in Scopus. The search was then refined, specifying dates of publication. CINAHL revealed 42 papers following revision, on closer inspection of the abstracts this revealed the majority of these were not relevant and 4 were selected. Cochrane generated 12 hits, 4 of which were relevant.
Scopus, Medline and Pro Quest continued to generate vast amounts of literature, 4122 results from Scopus, 479 from Medline and 64 for Pro Quest. Refining the search terms further by limiting papers to the other inclusion and exclusion criteria in table 1 rectified this and the results following the modifications revealed 5 relevant articles from Medline, 8 from Pro Quest and 11 in Scopus. (appendix 1).

Following the literature search 32 papers were selected. However on closer inspection 9 of the papers were replicated in some of the search databases. A further 19 papers were not readily available and due to time constraints were rejected. The 4 remaining papers were looked at again, in particular the references used in the papers to observe if any literature had been overlooked in the search. This “snowballing” revealed 2 more papers of which 1 was deemed relevant. In total 5 pieces of work were chosen for literature review.
The 5 pieces of literature were chosen following implementation of the Critical Appraisal Tool CASP (Critical Appraisal Skills Programme). CASP uses a systematic process of questions to review chosen literature and appraise its strengths and weaknesses. Using the CASP tool, the literature was scrutinised and specific areas of the literature were looked at in more depth. Type of research/ study size/ approach used /recruitment methods/ criteria eligibility/ population studied/drop outs/limitations/characteristics of study/emerging themes. Following this process all literature identified consisted of Quantitative studies. 4 of the Quantitative studies had used Randomised Control Trials in their methodology, and the remaining piece of literature a Large Longitudinal Cohort Study. Each piece of literature was linked within the hierarchy of evidence and categorised. (appendix 2).
The proposed question is directly trying to ascertain if any topical treatment would be of benefit to new-born infants. Quantitative research Studies lend themselves to the question posed as they involve many participants and the findings can often be applied in other contexts. Aveyard. (2010). Randomised control trials are seen as the gold standard of clinical trials and are often used to test efficacy or effectiveness of types of medical interventions. From the trials, often a recommendation can be made which in turn would impact on Health Professionals practice. From the literature selected themes were identified in the text, and explored in more detail. Table 2 indicates the themes identified in the literature. Due to time constraints the 4 most common themes were identified. Cord Separation Time, Mode of delivery, Adverse Effects and Parental Satisfaction. These themes were then looked at in more detail, to determine if they could answer the research question.

TABLE 2.

CORD SEPERATION TIME.
When trying to determine the most effective treatment to reduce the risk of infection in the new-born, cord separation time (CST) was a common theme identified in all the literature selected. As highlighted earlier the umbilical cord stump provides direct access whilst still attached, to the bloodstream of the new-born, hence the longer it takes to separate, increases the risk of infection to the new-born.
Kapellen et al (2009) conducted a RCT comparing dry cord care and the use of chlorhexidine (CX) powder. The results from the trial identified that the use of CX powder accelerated the separation of the umbilical cord, compared to dry cord care (no treatment). Kapellen et al (2009) also go on to state that cord separation time can be influenced by the use of antimicrobial agents. Only one form of antimicrobial agent was used in this trial and the authors have made generalised assumptions with regards to other types of antimicrobial agents and the influence they can have on cord separation time. The study was financially supported by Riesmser Arzneimittelwerke AG, who are a Pharmaceutical Company which could be viewed as a bias towards the use of antimicrobial treatments that they produce. A study carried out by Pezzati et al (2002) also identified a shorter separation time of the umbilical cord with the use of CX powder and link this to the importance of dehydrating effects on the umbilical cord. However in this study, CX was also used in liquid form and reported that it could prolong cord separation when used in this form. The authors emphasise the importance of dehydrating the cord and separation time. The study goes on to report that dry cord care, Salicylic sugar powder and Green clay powder were the most effective treatments when compared to the five other regimes included in their study. The literature identified that there were compliance issues with some of the other interventions randomised to the new-borns, however there is no evidence in the literature that suggests the data connected to the non-compliance was disregarded and therefore a bias of results cannot be ruled out.
Mullany et al (2013) and Soofi et al (2012) indicated from the studies they carried out that cord separation time tends to be longer with the use of antimicrobial interventions compared to dry cord care. These pieces of literature contradict the findings of Kapellan et al (2009) and Pezzati et al (2002). Mullany (2013) goes on to stress the importance of recognition of the need for different regimes of cord care in different communities, and even though a statistical significant increase was observed with regards to CST and dry cord care in their study, the author goes on to report this may not be appropriate treatment in high risk, low-resource communities. Soofi et al’s (2012) trial also supports this statement, however on closer inspection of their results, it is apparent they have dismissed cord separation time (CST). The results demonstrate that the dry cord regime compared to the 3 different treatment regimes resulted in CST of 1-2 days before the 3 other regimes. Soofi et al (2012) go on to report there was no difference in the CST between the 4 groups, which highlights inconsistencies in their analysis of results.
Perrone et al (2012) looked at a very different forms of treatment compared to the other trials selected. The results of CST with the use of Arnica Echinacea to treat the umbilical cord were favourable and the authors report a recommendation that it be introduced as a routine powder for new-born umbilical cord care, due to its low cost, acceleration of cord detachment and feasibility. The trial does not demonstrate if any long term effects were identified with the use of Arnica Echinacea on the new-born infant and there is no evidence of the study being approved by an ethics committee hence the safety of the trial could be questioned. The trial also made no attempt to use a placebo within the methodology and so the results identified may not be as feasible as portrayed by the authors.

MODE OF DELIVERY.
Three of the pieces of literature identified that the mode of delivery of the new-born could have an impact on cord separation and infection. Pezzati et al (2002) identify strict exclusion criteria in their methodology and go on to highlight areas for example gestational age, sex of new-born and mode of delivery as aspects that could possibly impact on their results. These epidemiological characteristics are not translated into the results and therefore questions need to be asked as to why they were disregarded as it is not clear.
Perrone et al (2012) also recognise that there may be significance with regards to mode of delivery. In their research they also make references to vaginal and caesarean births and the possible effects it can have with regards to infection. Despite these measures being recognised by the authors, they have failed to incorporate them into their findings and results. Therefore it is difficult to ascertain if the inclusion of these would have impacted on the results as a whole.
Following analysis of findings, Kappellen et al (2009) identified that new-borns delivered by caesarean section have a longer cord separation time due to bacterial colonization compared to new-borns by vaginal delivery. The randomization in this trial was stratified because of the expected differences of CST in the 2 groups. The literature does not identify why there was an expectation on the author’s part, however the results demonstrate a statistically significant (p<0.0001) difference between the two.
When looking at mode of delivery all the authors failed to look at the difference in length of stay in hospital with regards to mode of delivery. A longer stay in hospital as encountered by ladies undergoing caesarean deliveries, may impact on the findings, due to cleanliness, hand washing and adherence to regimes in a hospital setting.

ADVERSE EFFECTS.
As stated previously the WHO report that 1.5 million of neonatal deaths each year are due to infection. The emphasis and emerging theme in all the literature reviewed is linked to infection and adverse effects for example inflammation, bleeding, cellulitis, pus and offensive smell. The literature selected is from an array of socio economic settings, high and low risk communities and differing cultural values
Soofi et al (2012) primarily wanted to look at the risk of the new-born developing the infection Omphalitis. The randomised cluster trial was undertaken in Dadu and recruited 9741 new-borns. 4 different regimes were allocated to the new-borns. The authors wanted to demonstrate the effectiveness of Chlorhexidine in reducing Omphalitis. The results indicate that the use of Chlorhexidine on the new-borns umbilical cord can reduce the incidence of Omphalitis compared with dry cord care. Closer inspection of the literature reveals some inconsistencies. Fewer participants than estimated in one of the groups were identified due to problems with accessing them, the authors have acknowledged this but do not advise if this had an effect on their results. They also go on to state that no reliable information exists with regards to the population chosen and new-born omphalitis rates and devised their own baseline to make comparisons to. As there is no indication in the literature of approval from any board, it poses the question how ethical is the study.
The recognition of new-born omphalitis is an important factor in the literature. Community Health Workers (CHW) plays an important role in identifying and collecting results. Both Soofi et al (2012) and Mullany et al (2013) used CHW’s to gather relevant data. Soofi et al (2012) identified that questions could be asked of the diagnosis of omphalitis by the CHW’s as only limited training and supervision on the specific area had been undertaken. Mullany et al (2013) make no reference to training undertaken by the CHW’s if any at all and so could indicate limitations in the results, similar to those of Soofi et al. (2012).
Kapellen et al (2009) in their findings report a significant increase in adverse effects when dry cord care is implemented. They go on to report none of the adverse effects were serious. As previously identified this study was funded by a pharmaceutical company that produce antimicrobial products. The authors do advise that an observer bias cannot be excluded due to the nature of treatment versus no treatment, they do not indicate if a bias towards treatment was eradicated due to the nature of the funding.
Both Pezzati et al (2002) and Kapellan et al (2009) identify no difference in Omphalitis rates in treatment and non-treatment groups. Both however go on to make recommendations of the use of an intervention on the umbilical cord, as it is “superior” to dry cord care. Pezzati et al (2002) furthermore goes on to report that there is no evidence to confirm that dry cord care is harmful. This statement contradicts the recommendations made by the authors and thus makes the results appear incoherent.
No cases of Omphalitis were reported by Perrone et al (2012) in their trial. A small percentage of bleeding was noted, but was not classed as an adverse effect unlike the other pieces of literature. The results from this trial reported positive results with regards to cord separation time and adverse effects. A large cohort of 6323 new-borns were treated with Arnica Echinacea. Prior to treatment the cord was cleaned and imbued with peroxide hydrogen. The authors do not indicate if this intervention prior to treatment could have impacted on the results and no other literature selected employed this method, so its impact needs to be questioned. This study is also the first of its kind to use Arnica Echinacea and so highlights further research is needed with regards to this treatment, before recommendations of its use can be made.

PARENTAL SATISFACTION.
Parental Satisfaction was identified in four of the chosen pieces of Literature. As parents have ultimate responsibility for caring for their new-borns any form of care or intervention has to be accepted by them for it to be successful.
Pezzati et al (2002), demonstrates that the parents recruited to their trial were anxious with regards to not using any form of treatment on the umbilical cord. They go on to report that a short cord separation time was desirable for parents. Some of the treatments in this trial were deemed unacceptable by the parents, due to the nature of how they looked and that some treatments were new. These findings could impact on compliance and adherence with the treatment randomised to them. Mullany et al (2013), also identifies the importance of parents satisfaction with treatment. They identify that it is also of great importance to educate parents on topical treatments, and the need for concordance for them to be effective. Inadequate knowledge with regards to the pros and cons of the different treatments was identified by the authors in this study and the importance of communicating signs of infection, CST and normal appearance of the umbilical cord were identified as best practice.
Both Perrone et al (2012) and Kapellan et al (2009) indicate that no apprehension was identified within their treatments groups. Both go on to identify that the parental participants would go on to administer their chosen treatments to their next child. Only one form of treatment was employed in Perrone et al (2012) trial and so it is difficult to determine if parents would have been just as happy with no treatment, as no comparisons can be made.

CONCLUSION.
The literature surrounding care of the new-borns umbilical cord is vast. However this literature review has highlighted much of the literature is dated. It is clear from the findings that current practice is very much determined by the high/low income of the country. Tammy et al (2004) also identified historical practices and traditions were implemented rather than scientific investigation and justifications. In low income country’s were neonatal mortality and infection rates are high the literature supports the use of antimicrobials on the new-borns umbilical cord, this however may prolong cord separation time which has shown to cause anxiety in caregivers. Mullany et al (2013) emphasise the importance of education and communication in low income settings to help aide compliance with treatments. These findings have implications for Public Health in low income countries, as indicated by Soofi et al (2012), were many areas share similar cultural, social and economic characteristics.
The recommendations for high income countries appear unclear. The WHO (1998) recommend dry cord care, however it is clear from the literature critiqued that antimicrobial powders and liquids are being used in these settings along with some alternative therapies, despite the WHO recommendations. No clear reasoning for the use of interventions have been identified in the literature searched, and dry cord care versus interventions revealed negligible differences, which could raise the question why incur the cost of treatments if they are not necessary.
Health Visitors are ideally placed to promote health and educate parents on the care of their new-borns. The 4 principles of health visiting as defined by the Council for the Education and Training of Health Visitors (CETHV) overlap and are inter-related with regards to Promoting health and put Health Visitors at the forefront of the public health agenda. (Unite/CHPVA 2007). It is imperative that the advice they give is based on evidence, as this is viewed as gold standard of care. All the literature critiqued highlighted the lack of knowledge of caregivers surrounding umbilical cord care. The literature demonstrated that additional research is required in this area to provide an evidence base for practice. More research looking at natural healing of the umbilical cord and the education of caregivers in high income countries is required to achieve an accurate evidence base.

APPENDIX 1. DATABASE. | SEARCH TERM USED. | NUMBER OF HITS. | NUMBER RELEVANT TO SEARCH. | NUMBER SELECTED FOR FURTHER ANALYSIS. | CINAHLADVANCED SEARCH | UMBILICAL CORD,NEWBORN INFANT,UMBILICAL CORD INTERVENTIONS. | 4 HITS | 4 RELEVANT ARTICLES. | 2 SELECTED, 2 UNAVAILABLE. | COCHRANE | UMBILICAL CORD, NEWBORN INFANT,UMBILICAL CORD INTERVENTIONS,UMBILICAL CORD POWDERS. | 12 HITS + 9 TRIALS | 9 RELEVANT ARTICLES. | 1 SELECTED, 7 UNAVAILABLE,1 REPEATED FROM CINAHL. | MEDLINE | UMBILICAL CORD CARE, NEWBORN INFANTS. | 16 HITS | 6 RELEVANT ARTICLES. | 5 UNAVAILABLE,1 REPEATED FROM CINAHL. | PRO QUEST | UMBILICAL CORD,NEWBORN INFANT,CORD CARE. | 64 HITS | 8 RELEVANT ARTICLES. | 1 SELECTED, 2 REPEATED FROM CINAHL, 5 UNAVAILABLE. |

APPENDIX 2.

AUTHOR(S) /DATE. | TYPE OF STUDY. | HIERACHY OF EVIDENCE. | GRADING. | Pezzati, M. et al. 2002. | Randomised Control Trial. | 1- | A | Kapellen, T M. et al. 2009. | Randomised (Two Armed Control Trial. | 1- | A | Soofi, S et al. 2012. | Cluster Randomised Control Trial. | 1+ | A | Mullany, L C. et al. 2013. | Cluster Randomised Control Trial. | 1- | A | Perrone, S et al. 2012 | Cohort Study. | 2- | B |

ARTICLES SELECTED FOR LITERATURE REVIEW. Author(s)/Date | Title/Aim(s). | Type of Study. | Main Findings/Themes of study. | Strengths. | Weaknesses. | Pezzati, M . et al. 2002. | Umbilical cord care: The effect of eight different cord-care regimes on cord separation time and other outcomes. | Quantitative Study.Randomised Control Trial. | Cord separation time.Adverse Effects.Parental Satisfaction. | All infants were exposed to the same regime on admission to the ward, before starting randomised intervention. | Randomisation was allocated to one of regime of 8 for the month, thus the trial not being blind. | Kapellen, T M. et al. 2009. | Higher rate of adverse cord-related adverse events in neonates with dry umbilical cord care compared to Chlorhexidine powder. | Quantitative Study.Randomised (Two Armed) Control Trial. | Cord Separation Time.Mode of Delivery.Adverse Events.Parental Satisfaction. | Stringent Inclusion criteria. | No blinding was possible due to treatment versus no treatment.Caregivers were reporting on adverse effects, which could differ as no indication in research with regards to education of complications. | Soofi, S. et al. 2012. | Topical application of Chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of Pakistan. | QuantitativeStudy.Cluster Randomised Control Trial. | Infection and adverse effects.Cord Separation Time.Home v Hospital Delivery. | Randomisation of intervention was coded, by a computer-generated random sequence.3 day training programme implemented for professionals involved in the study, to ensure a standard of practice across the study. | Concerns raised with regards to diagnosis of infection by non-medical trained carers.Further traditional interventions introduced by parents( not excluded from trial) | Mullany, L C. et al. 2013 | Chlorhexidine cleansing of the umbilical cord and separation time. | Quantitative Study.Cluster Randomised Control Trial. | Cord Separation Time.Adverse Effects.Parental Satisfaction.Hand Washing. | Large participant numbers. | Compliance problems with participants. | Perrone, S. et al 2012 | Efficacy of Arnica Echinacea powder in umbilical cord care in a large cohort study. | Quantitative Study.Cohort Study. | Cord Separation Time.Adverse Effects.Parental Satisfaction. | Low cost Intervention. | No Placebo. | |

BIBLIOGRAPHY.

Aveyard, H. (2010) Doing a Literature Review in Health and Social Care. Open University Press. England.

Cappuro, H. (2004) Topical cord care at birth: RHL commentary. [Online]. Available from: http://www.apps.who.int/rhl/newborn/cd001057_capurroh_com/en. [Accessed 2 March 2014].

Critical Appraisal Skills Programme (CASP). (2013) Making Sense of Evidence. [Online]. Available from: http://www.casp-uk.net/?_escaped_fragment_=casp-tools-checklists/c18f8. [Accessed 18th March 2014].

Davies, L. and Mc Donald, S. (2008) Examination of the New-born and Neonatal Health. Edinburgh: Churchill Livingstone.

Fraser, D M and Cooper, M A. (ed.) (2009) Myles Textbook for Midwives. Edinburgh: Churchill Livingstone.

Kapellen, T. Gebauer, C. Brosteanu, O. Labitzke, B. Vogtmann and Kiess, W. (2009) Higher Rate of Cord Related Adverse Events in Neonates with Dry Umbilical Cord Care Compared to Chlorhexidine Powder. Neonatology, (96), pp 13-18.

Karumi, J. Mulaku, M. Aluvaala, J. English, M and Opiyo, N. (2013). Topical Umbilical Cord Care for Prevention Of Infection and Neonatal Mortality. Pediatric Infectious Disease Journal, (32) pp 78-83.

BIBLIOGRAPHY.

Mullany, C. Rasheduzzaman, S. Arifeen, S. Mannan, I. Winch, P. Hill, A. Darmstadt, G and Baqui, H. (2013) Chlorhexidine Cleansing of the Umbilical Cord and Seperation Time : A Cluster-Randomised Trial. Pediatrics, 131, (4), pp 708-71.

Nursing and Midwifery Council (NMC). (2010). The Code: Standards of conduct, performance and ethics for nurses and midwives. [Online]. Available from http://www.nmc-uk.org/Publications/Standards/The-code/Provide-a-high-Standard-of-Practice-and-care-at-all-times-/. [Accessed 19th February 2014].

Perrone, S, Coppi, S, Coviello, C, Cecchi, S, Becucci, E, Tataranno, M L and Buonocore, G. 2012. Efficacy of Arnica Echinacea powder in umbilical cord care in a large cohort study. Journal of Maternal-Fetal and Neonatal Medicine, 25 (7),pp. 1111-1113.

Pezzati, M. Biagioli, E. Martelli, E. Gambi, B. Biagotti, R and Rubaltelli, F. (2002). Umbilical cord care: the effect of eight different cord-care regimes on cord separation time and other outcomes. Biology of the Neonate. 81, pp 38-44.

PICO. Asking a good question. (2008). [Online]. Available from: http://www.usc.edu/hsc/ebnet/ebframe/PICO.htm. [Accessed 26th February 2014].

Soofi, S. Cousens, S. Imdad, A. Bhutto, N. Ali, B and Bhutta, Z. (2012) Topical application of chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of Pakistan: a community based cluster-randomised trial. The Lancet. 379, pp1029-1036.

BIBLIOGRAPHY.

Tammy, P. Mc Connell, M. Connie, W. Lee, E. Couillard, M and Sherrill, W. (2004) Trends in Umbilical Cord Care : Scientific Evidence for Practice. Newborn and Infant Nursing Reviews, Vol 4, No 4 (December), 2004 : pp 211-222.

The National Institute for Health Care Excellence. (NICE) (2006). CG37 Postnatal Care. NICE Guideline. [Online]. Available from: http://www.nice.org.uk/nicemedia/pdf/CG37NICEguideline.pdf. [Accessed 16th February 2014].

The World Health Report 1998. Life in the 21st century. A vision for all. [Online]. Available from: http://www.who.int/whr/1998/en. [Accessed 10th March 2014].

Weightman, A. Ellis,S. Cullum, A. Sander ,L and Turley, R. (2005) Grading Evidence and Recommendation for Public Health Interventions: developing and piloting a framework. [Online]. Available from: http//www.nice.org.uk/niceMedia/docs/grading-evidence.pdf. [Accessed 10th March 2014].…...

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...The author’s intention is to identify an aspect of clinical practice which lends itself to change at a micro level. The definition of a micro-change is an intervention of change aimed at the individual or the way small teams work. The micro-level change is not to be confused with a service change (Walsh, 2009). When considering a change in practice we need to firstly understand why we need to make a change? Secondly when making a change, we need to justify a decision. This can be achieved by exploring the components which encompass decision making within nursing practice. Cullum et al (2007) identifies four requirements:-Clinical experience, valid researched evidence, available resources and lastly but no less important the patient preferences and experiences. The area of clinical practice to be studied is within a community district nursing team consisting of 7 qualified nurses and 3 health care assistants. The location is situated within a seaside town with a large population of over 65 year olds. Through clinical experience, the author has found a flaw in quality of care when nursing staff are using the overview assessment document which has been adapted from the single assessment process produced by the Department of Health (DOH, 2002). When assessing nutrition there is a series of six questions and an asterisk to consider the “Malnutrition Universal Screening Tool” (MUST, 2003) however experience in practice would suggest the tool (MUST, 2003) isn't used and a......

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Evidence Base Practice

...Discuss how evidence -based practice is applied in your practice setting and describe the desired outcome achieved through this approach. “Evidence-based practice is an interdisciplinary approach to clinical practice”.(wiki) Its purpose is to improve the quality of patient care and patient outcome In critical care unit the area in which I practice evidence based practice is been developed for reduction and prevention of critical illness neuromyopathy: profound weakness. To accomplish this, a supportive treatment approach has been implemented. The treatment of all sources of inflammation is aggressively treated. Potentials for infections is being addressed by early removal of Foley’s, iv lines out when no longer need, Peripheral iv changed every 72 hours, and piccline are removed when it is evident that the patient is febrile for 24 t0 48 hour period. Another treatment approach is early weaning of patients on mechanical ventilator, also the entire interdisciplinary team is involved in a mobility plan for all patients admitted the unit. Early weight-bearing and ambulation is encouraged. Control of schedule for mobilizing patients out of bed is the responsibility of members in physical therapy department. Each patient may be up for about two hours, the number of patient to be up and the time they should be up is posted for both day and night shift. For vented patients the Respiratory therapist, the nurses and the nursing assistant together as team is responsible for......

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Evidence Based Practice

...Examine the ways that health professionals can use the five steps of evidence-based practice (EBP) as a practical framework to overcoming barriers to locating, appraising and applying best research evidence. Use an occupational health and safety practice as an example. Examples of occupational health and safety practices include: *  Use of professional protective equipment (e.g. gloves) *  Safety considerations when using equipment (e.g. sharps) *  (or a topic you select yourself in negotiation with your LIC) Health professionals are very good at seeking information from their clients and their families and also from the settings in which they work but however they have not been as aware of the information that they can gain from research. Although they need information from many sources, evidence based practice shows how research can also play a role in informing clinical decisions, (Hoffmann ,2010). Health professionals use the five steps of evidence-based practice (EBP) as a structure to overcoming barriers and applying best research. Examples of this include use of professional protective equipment and safety considerations when using equipment. Liamputtong (2010) states that evidence based practice is a “process that requires the practitioner to find empirical evidence about the effectiveness or efficacy of different treatment options and then determine the relevance of the evidence to a particular clients situation” (pp. 252). Sackett (1996,......

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Evidence Based Practice

...EVIDENCE BASED PRACTICE BENCY GNANASIGHAMANI AMERICAN SENTINEL UNIVERSITY Introduction Medical and health care is one of the most dynamic human disciplines, and large amounts of money are spent annually on high-quality and sophisticated research, resulting in an exponential growth in health care literature. Regularly, new and more effective medicines, medical devices, and procedures are invented. One major objective behind all these efforts is to help doctors, nurses, and medical technicians provide the best possible care and treatment to patients. In addition to using traditional and well-established procedures and practices, health care practitioners are adopting innovative interventions that are based on best practices as well as solid research-based evidence. Evidence-based practice is one such technique and is quickly gaining popularity due to its potential to effectively handle clinical issues and provide better patient care (ANA 2003). Implementation of Evidence Based Practice places additional demands on nurses to apply credible evidence to individual client situations through searching related evidence, using clinical judgments, and considering client values and system resources. To effectively apply the Evidence Based Practice process, in addition to the basic skills required to undertake nursing work, a nurse must have the ability to: identify knowledge gaps, formulate relevant questions, conduct an......

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Evidence Based Practice

...“The critical appraisal of the research evidence associated with an area of my professional practice” Introduction I am going to critically appraise of research evidence on treatment of urinary stress incontinence in women with obesity. I chose this topic because currently I am working in urology department in hospital X, I am always have the chance to deal with women experiencing stress incontinence. In current practice we will teach them behavioral intervention program (pelvic floor exercise and bladder training) to lower the severity of urine leakage. That is why I want to explore more on this issue and see whether the use of vaginal cones also effective in treatment with behavioral intervention program. Obesity is a common problem in developed countries, with an incidence of 33% (Roreyt 1998), this problem may directly leading to stress urinary incontinence (Ouslander 1996) which may hinder the normal daily life of an adult. In Hong Kong Hospital Authority (HA) policy, there are no guideline in related to treatment regarding stress incontinence, it is always depends on surgeon’s preferences. Therefore I want to search for research evidence in associated with treatment of urinary stress incontinence which may beneficial in my working place. Main Body The two answerable questions formulated using PICO tool are: Quantitative Question – In women with obesity, how does behavioral intervention program compared to vaginal cones influence the occurrence of......

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...Evidence-Informed Practice: An Evaluation of the David Bennett Inquiry Report In this essay I will evaluate the David Bennett Inquiry Report, which was set up by the North, Suffolk and Cambridgeshire Strategic Health Authority (NSCSHA) to investigate the death of Mr David Bennett. I will define evidence-informed practice (EIP) and summarise the inquiry report. I shall highlight and critically analyse some of the key issues raised in the report in relation to ethnic minority issues. Finally, I will discuss the implications of evidence-informed practice for social work as well as my own future practice. EIP in social work began in the early 1990s when contemporary writers Geraldine MacDonald and her colleagues wrote articles very much in contrast to earlier reviews; they looked at results from studies such as quasi-experimental studies and client opinion studies about the effectiveness of social work practice. This led to good outcomes for social work practice (Webber, 2011) [Online]. Evidence-informed practice in social work has been described as: ‘Evidence based social care is the conscientious, explicit and judicious use of current best evidence in making decisions regarding the welfare of those in need of social services.’ (Sheldon and Chilvers, 2000, p.5, adapted from Sackett et al., 1996 cited in Webber, 2011, p.3) Webber (2011) and Sheldon and Chilvers (2000, p.5, adapted from Sackett et al., 1996 cited in Webber, 2011, p.3) both define EIP as using effective......

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...Question: Describe Evidence Based Practices. Nurses are constantly challenged to stay tuned with new information to provide the highest quality of patient care. Nurses are challenged to expand their “comfort zone” by offering creative approaches to old and new health problems, as well as creating new and innovative programs that make a difference in the health status of citizens. This challenge can best achieved by integrating rapidly expanding research and evidence based on health into the care of patients and their families (Schneider, Whitehead, LoBiondo-Wood & Haber, 2013). This essay will describe what is and how to use Evidence Based Practices in the field of nursing. EBP is the use of best research evidence, along with clinical expertise, available resources and patient’s preferences to determine the optimal assessment, treatment or management option into a specific situation (Liamputtong, 2013, p.286). The EBP activities include five steps: 1. Ask an answerable clinical question: The first step in research utilization is identifying areas of practice that have scope for improvement via reflection and observation of the process of care. When the problem has been identified, an EBP question is formulated. The useful method for creating the question is PICO (P=Patient type or Population, I=Intervention of interest / idea, C=Comparison or option, O=Outcome) (Borbasi & Jackson, 2012, p.197). 2. Acquire the best available evidence: It is......

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...Implementation of Evidence-Based Practice Sheila Wright Submitted to Sharon Mooney, RN, MSN in partial fulfillment of NR 460R Evidence-Based Practice in Nursing Regis University April 9, 2010 Implementation of Evidence-Based Practice Throughout history, nursing practice has experienced change. Florence Nightingale initiated the greatest change in nursing in the mid-1800’s when she gathered data regarding the morbidity and mortality of soldiers (Chitty & Black, 2007). Nightingale recognized there was a need for change to improve patient outcomes. Her determination to provide the best possible care, based on the evidence she gathered, has inspired a profession. Today, the process of using research to care for patients is referred to as evidence-based practice. The purpose of this paper is to define and explain the importance of evidence-based practice, discuss qualitative and quantitative research studies which affect medical-surgical areas, and barriers preventing research utilization and how they may be overcome. Definition of Evidence-Based Practice There are numerous definitions of evidence-based practice (EBP). EBP is defined by Boswell and Cannon (2007) as, “A research-based, decision-making process used to guide the delivery of holistic patient care by nurses” (p. 340). Cope (as cited in Chitty & Black, 2007), defines EBP as “using the best available research findings to make clinical decisions that are most effective and beneficial for......

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...Evidence Based Practices Abstract Quality nursing and outcomes have a strong correlation with evidence based practices, a model that guides patient provider decision making and health care. Evidence based practices uses contentious and judicious use of current best evidence in decision making about the care of individual patients. Strong nursing and organizational leadership is needed to invest in nurses ability and the resources to facilitate evidence based practices. With business principles applied to quality health care the return on investment can increase revenues, saving costs, increases patient safety, and achieves the highest quality care. Keywords: clinical decision making, patient safety, best health care outcomes Evidence Based Practices in Nursing Evidence based practices occurs in many disciplines but most recently it has occurred in the discipline of nursing. Evidence based practices helps to identify and recognize the best health outcomes for patients and their families obtained through clinical expertise and best scientific evidences. Health care professionals are constantly asking questions in regards to health care practices in regards to how and why practices are being performed the way they are. Health care professionals want to know if the way they are caring for a patient is the best way or is there another method that is more effective. In a dynamic health care setting these questions are being asked to ensure quality care and safety for......

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...Significance of Having a Multidisciplinary Team 3 Abstract The growing prevalence and hospital acquired pressure ulcers is an immediate concern. The major challenge is the A major challenge is the lack of knowledge and skills in wound identification, management, treatment and prevention. This, along with other factors, creates poor patient care and vast costs to the pertinent facilities. The solution is to have interprofessional collaboration. The utilization of current advanced practice nursing staff as a resource for floor nurses and other involved healthcare workers is a must. This would obtain certification in wound care and be responsible for the ongoing continued education for wound prevention, monitoring and maintenance. The staff will be educated and trained at quarterly intervals on wound identification, staging, prevention, maintenance and monitoring. Key words: wound care, evaluation, pressure ulcers, multidisciplinary, specialist, evidence The Significance of Having a Multidisciplinary Team 4 Problem Identified The Centers for Medicare & Medicaid Services (CMS) declared in October of 2008 that it will no longer provide reimbursement for hospital acquired pressure ulcers (HAPUs) because it is a preventable occurrence (CMS, 2014). Even though the percentages of occurrences have declined since then, HAPUs continue to cause financial strain on institutions (estimated $9.1- $11.6 billion dollars loss annually)......

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