PEER REVIEW OF CLOSED ETS COMPARED TO OPEN ETS IN MV ICU PATIENTS

Answer

1. Peer Review of Closed ETS Compared To Open ETS in MV ICU Patients

    

   Part 1

   From a general point of view, a great work has been done in developing the work on the study that aimed at comparing closed endotracheal tube suctioning (ETS) to open ETS in mechanical ventilation (MV) intensive care unit (ICU) patients. The work is comprehensive, current, and evidence supported, making it be of a great quality. However, there are some few concerns that will be highlighted in this feedback that if employed in further studies will improve the quality of findings with regard to closed and open ETS for MV ICU patients. 

   Purpose/Aim of Review

   The aim of the critical review was stated. The critical review aimed at determining whether closed ETS results in a comparatively lower prevalence of VAP than open ETS in MV ICU patients. The statement explicitly brings out that two kinds ETS would be compared, and that either of the two types to some extent cause VAP. Generally, the development of the critical review’s was illustrative comprehensive as far as the study was concerned.

   Potential Benefits

   The critical review clearly articulated why the review was relevant and necessary. The review began by highlighting the significance of ETS to patients in ICU by giving details that ETS is among the most common clinical procedures that are performed on patients requiring MV in ICUs. There are types ETS: open endotracheal suction systems (OSS) as well as closed endotracheal suction systems (CSS). Nonetheless, the review highlights that ETS has been reported as a causative exogenous danger factor for the development of ventilator-associated pneumonia (VAP). Additionally, the review gave prevalence and incidence of MV incurring VAP, indicating that VAP is among leading causes of death among nosocomial infections.

   Moreover, the review acknowledges that studies have been done to compare the effects of CSS and OSS upon VAP prevalence. However, the review indicates that literature findings are conflicting, controversy persist, as well as there is no contemporary agreement upon which the apparatuses ought to be used for prevention of VAP in clinical practice (Dhawan, 2018).

   Significance of the Issue to Health Care Practice

   From the review, it can be deduced that by understanding harmful impacts of VAP mentioned in the review in addition to the lack of medical guidelines on CSS and OSS on MV patients, any ability of minimizing prevalence is important so that the best evidence-based practice can be recommended. Despite the fact that the significance of the review was stated, the significance was not sufficiently clear and required a lot of brainstorming to comprehend. An extra comprehensive review on this topic would be necessary to provide greater intuition for a reader regarding the topic and how the MV patients can be addressed with regard to the use of ETS. Additionally, the significance using either OSS or CSS is not very clear enough for the reader. As such, there is a need to make clear the significance and limitations of either the OSS or CSS for a better understanding by the reader.

   Effective Article Search, Retrieval and Selection Process

   With the knowledge that a literature search is aimed at identifying a detailed list of primary sources to give proof for answering a research question, the review’s systematic search strategy was clearly spelt out, starting with the first step that involved identifying answerable research questions as well as suitable keywords to produce maximum search outcomes. The PICO framework was employed during the formation of a focuses research question and to facilitate the identification of keywords. The keywords that were used are well defined in Appendix 1: Table 1.1 for inclusion and/or exclusion for the study.

   Similarly, the process of article retrieval was well defined and documented. Nonetheless, the process of selecting articles and documents to use ought to have been refined further since there are several documents that have been published on the review’s topic between 2009 and 2019, implying that there was no need of incorporating studies that were done earlier than 2010. Additionally, there was no need of extending the publication year of document to use since the inclusion criteria and the keywords stated could be well related to enhance the search of relevant documents for use.

   The inclusion or exclusion criteria for the review was sufficiently detailed. This functioned to enhance the validity, reliability, and credibility of the findings of the review. For a document to have been used in the review, it must have contained MV adult in ICU patients who are in need of CSS or OSS. The use of both randomised control trials (RCT) and cohort studies gave a significant boost to the validity and generalizability of the review. Nonetheless, with the use of more search words and searches of more libraries, publications and articles from authorized organisation websites would have given more information on the study. Generally, the review gave a vivid explanation of an effective selection, retrieval, and article research for the review despite the loopholes that were inherent of the process.

   Assessment of Approaches/Techniques Used In Studies

   The Joanna Briggs Institute (JBI) critical appraisal tools (cohort studies and RCT) were employed for the evaluation of articles’ methodological quality. A summary of the checklist for the two tools were also given in Appendix 2: Tables 2.1 and 2.2, along with a subsequent appraised researches in Tables 2.3 and 2.4. A detailed explanation of how each of the two tools were used was provided. However, it was noted that while the tools may have been instrumental in the study, care needs to be taken in case they are used for such a study. Regarding the cohort study, the review indicated that there were high chances of recruitment bias as a result of a slightly higher SAPS (slightly acute physiology III score) in the review’s CSS group (Aromataris & Munn, 2017). Exclusion and inclusion criteria for the cohort study tool. Additionally, the exposures were well defined for cohort study tool.

   While much care was taken in the employment of the cohort study tool, the reviewed acknowledged that it was not clear if repeatability and reliability of measurements of happened. From the review, only non-study period was used, and this potentiated a user bias during the study. From the cohort study tool, it was apparent that several weaknesses with the small sample sizes, lack of randomization, and single units settings. Notwithstanding the fact that the findings of the assessment reliability and validity were suitably gauged based upon existing analytical criteria, the singularly employing the medical pulmonary infection score apparatus could possibly limit diagnostic accuracy.

   From the RCT analysis, the review indicated that internal validity was upheld via true randomization by using computer-produced programs as well as the internet. Allocation concealment was not stated in a number of articles that were used besides the fact that there was a possibility of recruitment bias in the studies that were considered in the review as a result of higher ischaemic heart disease in CSS groups. The review indicated that through critical assessment checklists allowed weaknesses and strengths of the articles that were employed in the review for assessment.

   Rational Synthesis of Research Proof

   Four main themes were highlighted in the review. Richardson-Tench et al. (2011)’s analytical framework was employed to guide the process of identifying the major themes in the articles that were considered for this review. The review described the analytical framework and the summary is given in Appendix 4: table 4.1 and Appendix 43: Table 3.1. The review highlighted that there was no single theme present across all the studies that were reviewed. A summary table was included in the review to provide a good summary of the major findings of each of the studies that were included. The themes are as discussed here below.

   Theme 1: Use of CSS and OSS results in similar VAP incidence. The review established that the employment of CSS never resulted in minimized prevalence of VAP in MV ICU patients relative to OSS (Elmansoury & Said, 2017) and that the findings that occurrence amongst the two systems was alike and no study identified that CSS were superior to OSS with regard to VAP minimization. Nonetheless, this finding could not generalized due to weaknesses that were noted in most studies that were considered for the review that possibly gave false information regarding the high incidence of CSS. It could be inferred that if it were not for the identified limitations, CSS could have produced minimized as opposed to similar VAP prevalence rates when juxtaposed. Nevertheless, the weakness were pronounced to allow for such an inference.

   Theme 2: CSS reduces VAP incidence over OSS. It was established that CSS substantially minimized VAP prevalence over OSS.  Jongerden et al. (2007) identified that despite the fact the general prevalence of OSS and CSS was similar, CSS considerably decreased the frequency of VAP in late onset VAP.  Nonetheless, most of the studies that were reviewed did not differentiate late-onset and early VAP in their results, making the findings unrealizable and invalid to some degree. Due to the weaknesses of the studies, the review established that VAP was substantially minimized in the CSS group. However, the sample sizes that were used by most of the studies that were reviewed were insufficiently empowered, allowing room for their findings to be questionable.

   Theme 3: Clinical considerations required. The reviewed subdivided this theme into three. First was cost. From the review, it was clear that cost ought to be considered when determining to use OSS or CSS (Joseph et al., 2010). While there was a general finding that minimization of VAP through CSS use as higher chances of producing greater general cost savings owing to the high expense of VAP treating, there was no evidence that OSS was sufficiently compared in terms of cost to CSS (Juneja et al., 2011). The reviewed proved that CSS costs are cut with linger term MV patients relative to single-us catheters.

   Second was subglottic suctioning (SS). Various findings were obtained regarding this sub-theme. Despite the various findings that were obtained regarding this sub-theme, there were no substantial evidence to warrant the findings since each of the studies largely used different variables. Additionally, whereas there was a general finding that subglottic suctioning had a larger general impact upon VAP minimization relative to OSS and CSS, there was no sufficient proof of these findings.

   Third was alternate consideration. Alongside VAP incidence, several clinical considerations should be taken into consideration when determining whether to employ OSS or CSS. This finding was supported by various evidences that involved the use of various procedures, techniques, and participants. Nevertheless, there was some element of conflict in the results that were found.

   Answers to the Issue/Question/Problem/ Based Upon Evidence

   With the ultimate aim of evaluating the effects of CSS relative to OSS in connection with prevalence of VAP, the review provided an elaborate and succinct analysis of several articles. Most of the articles indicated that there was no substantial dissimilarity between suctioning with either CSS or OSS upon the prevalence of VAP in MV ICU patients (Jung et al., 2008). The reviewed revealed that is appropriately used combined with aseptic precautions, prevalence of ought to be comparable. Nevertheless, there are some worries that certain of the designs that were used in the studies that were used contained bias, thus contributed to false findings. Additionally, the findings were contradictory since Kalanuria et al. (2014) established a significant fall in the frequency of VAP with the use of CSS, especially amongst late-onset VAP. With the conflicting findings, it can loosely be inferred that the use of CSS will not increase VAP incidence.

   Additionally, the review established that when determining the system that is suitable for employment, cost, SS along with other clinical indicators ought to be reviewed. The review discusses the strengths and weaknesses associated with the abovementioned factors for consideration, giving a detailed view regarding them. Nonetheless, it can be gleaned from the review that there are some conflicts in the findings due to the kinds of data that were used. Additionally, the review highlighted that there are insignificant or non-conclusive results when assessing whether CSS or OSS was superior in minimizing VAP prevalence. 

   Identification of Gaps

   Gaps were identified and comprehensively discussed in the review. Some of the limitations in the review included low sample size, competition of the literature review by the sole researcher, the strict inclusion criteria, the use of different suctioning techniques, and the fact that most of the reviewed articles primarily concentrated upon VAP prevalence, among others. With proper identification of the gaps, future studies should consider the limitations of the review for better findings.

   Potential Implications of Review Evidence

   The discussion of potential implications of the study is clear, comprehensive, informative, and systematic besides having recommendations for each possible weaknesses. Due to various conflicting findings of the studies that were used for this review, the implications of the review is still questionable. Taking into consideration the various concerns in the studies, the author of the article has sufficiently given recommendations on some of the considerations that should be taken and measures that should be put in place for better findings in future.

    

   PART 2

   2a.                                                                        

   The critical review process sufficiently and satisfactorily applied to the research question that I focused on answering. The process systematically and vividly spelt out the steps that were to be taken to realize the desired outcomes. Specifically, the search process for relevant materials helped me to narrow down my concentration of the many literatures available both online and offline to only those that were pertinent to the answering the question I settled on. Additionally, by undertaking a synthesis of the selected papers, I was able to develop a detailed understanding of the research question I sought to answer while discussion allowed a room for demonstrating how my synthesis findings could possibly be employed into medical practice.

   2b.                                      

   From the review, it is evident that due to few studies that were obtained, the inclusion criteria was increased from 10 to 15 years from 2019 backwards. Going that way, I would be able to get several papers relevant to the study, especially by modifying the keywords that I would be using for my search process.

   2c.

   Yes, since the topic is well defined and explicitly brings out what the reader of the document should expect from reading the document. Similarly, information gathered from it can directly be used by clinical practitioners for the better by understanding the relationship between the kinds of treatments VAP in MV ICU patients and factors that should be taken into consideration when deciding which strategy to use when dealing with an MV patient.   

   2d.

   Whereas the research topic may eloquently be speaking for itself, there is a need for flexing the inclusion/exclusion criteria, to increase the study sample size, and the assessment ought to articulate both how the study is pertinent to clinical practice and how clinical practitioners will implement them to better MV ICU patients’ health care results.

   2e.

   To increase emphasis upon interdisciplinary practice, no health care practitioner should at any time base their clinical practice on a single evidence but must involve findings of other clinical practitioners, especially when a patient has to undergo several examinations by various care providers before they can get their medication. Similarly, clinical practitioners should be encouraged to work in conjunction with their colleagues so that they can clearly articulate their patient care needs and how to implement them within the contemporary clinical environment.

    

   2f.

   Undoubtedly, the focus of a critical review is to enhance health results for care consumers. For this reason, learners ought to have the ability to demonstrate through the various initiatives and works that they do how they will be able to make use of the outcomes of their researches into real world clinical practice and setting to enhance care consumer health results.  A section of a review should explicitly show how the findings of a review will be made use of as well as reviewed within the clinical environment. A review process should equally identify or spell out how it will benefit the care consumers as well as transform their health results and how the targeted benefits of a review can be measured.

    

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