The Research Process and Evidence-Based Practice

As in practice, developing an evidence-based practice, QI or research project requires much input and many revisions of your thinking as you review the literature, talk to colleagues and consult with clinical and research experts. NOTE: you should review the literature related to the problem to be sure you have evidence about the problem (not solutions). Think of this as a document you could use as an outline for writing a statement to convince others that this is something that should be addressed in your practice setting. Use an outline not narrative format.
What is the patient care problem?
What is the health issue, outcome, etc that is in need of intervention or needs to be improved? Think of the poor outcome(s) that prompted you to consider the issue. What motivated you to identify this issue? ● Infections are a leading cause of death in neonates and The World Health Organization acknowledges neonatal sepsis as a major global health concern.
● Due to immaturity of the immune system, babies may not show all signs of infection, and delay in treatment may lead to severe illness or death (Kuti et al., 2019).
● Neonatal infections may be acquired through exposure to the contaminated secretions of the birth canal or contact with the contaminated.
● Major sources of infections in the neonate are contaminated hands of mothers, other caregivers, and health care workers, as well as hospital equipment (Kuti et al., 2019).
● Contaminated hands play a major role in community‐acquired and hospital‐acquired neonatal infections, particularly among preterm infants, who are most susceptible.
● The bacteria most implicated in early neonatal sepsis are Group B streptococcus and Gram‐negative bacilli (Mtitimila et al., 2004).
● Management options remain basic in newborns, mainly consisting of early antibiotics and supportive treatment, which is problematic given the growing antimicrobial resistance (Popescu et al., 2020).
● Neonatal infections often lead to prolonged hospital stay, early and late complications, and huge economic burden.
● Neonatal infections can be prevented when caregivers of these babies practice good hand hygiene, therefore we need to find solutions to better implement good hand hygiene practices in communities and health care facilities as it may reduce the risk and incidence of neonatal infections and deaths.
Kuti BP, Ogunlesi TA, Oduwole O, Oringanje C, Udoh EE, Meremikwu MM. Hand hygiene for the prevention of infections in neonates. Cochrane Database of Systematic Reviews 2019, Issue 5. Art. No.: CD013326. DOI: 10.1002/14651858.CD013326. Accessed 10 February 2021.
Mtitimila EI, Cooke RWI. Antibiotic regimens for suspected early neonatal sepsis. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004495. DOI: 10.1002/14651858.CD004495.pub2. Accessed 11 February 2021.
Popescu, C. R., Cavanagh, M. M., Tembo, B., Chiume, M., Lufesi, N., Goldfarb, D. M., … & Lavoie, P. M. (2020). Neonatal sepsis in low-income countries: epidemiology, diagnosis and prevention. Expert review of anti-infective therapy, 18(5), 443-452.
Who and what is affected by this problem?
Describe the population you are focusing on (age, gender, race, ethnicity, geographic location, etc.). Individuals? Clinicians? Families? Systems? Provide evidence/data.
● Neonates are the affected population. Neonatal sepsis is the substantial cause of morbidity and mortality among term and preterm infants.
● The source of the pathogen might be attributed to an in-utero infection, acquisition from maternal flora, or postnatal acquisition from the hospital or community.
● The timing of the exposure is also important to consider. Inoculum size, immune status of the infant, and virulence of the causative agent impact the clinical expression of the sepsis.
● Immunological immaturity of the neonate also may issue an impaired response to infectious agents.
● Due to decreased IgG antibodies and incompetenet opsonization, the immune system of neonates is compromised.
● Also, the increased need for invasive devices (vascular access, endotracheal tube, feeding tubes and urinary tract catheters) is associated with severe illnesses.
● These findings are especially evident in premature infants with prolonged hospital stays and/or need for invasive procedures that place the neonate at an increased risk for hospital-acquired infections.
● Very low birth weight infants (VLBW<1,500g) is another strong precursor to sepsis.
● African American infants have an increased risk of GBS (group B streptococcus) and LOS (late-onset sepsis), likely secondary to the higher rate of GBS carrier rates in African American females.
● Males have a higher risk of sepsis and meningitis, especially with gram-negative enteric bacilli.

Singh M, Alsaleem M, Gray CP. Neonatal Sepsis. [Updated 2020 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:

Shane, A. L., Sánchez, P. J., & Stoll, B. J. (2017). Neonatal sepsis. The Lancet, 390(10104), 1770–1780.

What is the scope of the problem?
How extensive is the problem for the people it affects?
Provide evidence/data. ● It is estimated that sepsis affects between 4 and 22 neonates per 1000 live births globally (Glaser et al., 2021).
● Infants with extreme prematurity and/or very low birthweight (less than 1500g) are most likely to be diagnosed with sepsis (Glaser et al., 2021).
● Early onset sepsis (within 72 hours of birth) is usually associated with maternal factors such as lack of prenatal care, substance abuse, premature birth and maternal infections (Glaser et al., 2021).
● Late onset sepsis (LOS) occurs 72 hours after birth or later and is considered to be caused by the environment. Studies show that a high acuity unit with increased workloads for staff lead to decreased compliance with infection control protocols and increased LOS risk (Glaser et al., 2021).
● Neonatal sepsis ranks as the 3rd most common cause of newborn mortality with approximately 336,000 deaths per year. It is also ranked the 16th largest contributor to years of lost life across all age groups (Kim et al., 2020).
● Neonatal sepsis mortality rates are 2% in term infants and 20% in preterm infants (Kim et al., 2020).
● Neonatal sepsis is shown to be associated with multiple types of developmental delays among survivors (Kim et al., 2020).
● A study in 2013 considered results from neurodevelopmental assessments of children between 30 and 42 months of age who had confirmed neonatal sepsis and were born at 29 weeks gestational age. The study suggests cognitive delays are suffered by the children (Alshaikh et al., 2013).
● Family members of infants who die or experience long-term complications as a result of sepsis report tremendous grief and regret (Kim et al., 2020).

Alshaikh, B., Lee, W., Henderson, E., Yusuf, K., & Sauve, R. (2013). Coagulase-negative staphylococcus sepsis in preterm infants and long-term neuordevelopmental outcome. Journal of Perinatology, 34, 125–129.

Glaser, M. A., Hughes, L. A., Jnah, A., & Newberry, D. (2021). Neonatal Sepsis: A Review of Pathophysiology and current management strategies. Advances in Neonatal Care, 21(1), 49–60.

Kim, F., Polin, R. A., & Hooven, T. A. (2020). Neonatal Sepsis. BMJ, 371, 3672–3672.

What are the factors that contribute to the problem?
Risk factors, individual, social, policy, environment, etc. Provide evidence/data.
NOTE- these are the things that may be fixed!
What cannot be changed? ● Neonatal sepsis may be associated with long working hours. Exhaustion and lack of concentration may cause healthcare workers to skip or inadequately perform hand hygiene.
● Research suggests that hand antisepsis is significantly reduced when working 12-25 hour shifts as compared as to 8 hours shifts. Lack of concentration and fatigue may cause this reduction.
● Health care workers working day shifts have better compliance with hand hygiene as compared to night shift, this may be due to disruption of the circadian rhythm which can impact work performance and alertness.
● Evidence suggests that nurse workload is significantly associated with elevated levels of neonatal sepsis. An inadequate staffed unit will lead to a higher nurse-patient ratio which will inhibit nurses to focus on the task at hand. Nurses will have less time to perform adequate hand hygiene. Higher nurse-patient ratio also means faster spread of pathogens from one patient to the other.
● Lack of knowledge on prevention and detection in another contributing factor. Early detection is key and inability to recognize early physiologic and behavioral indicators of neonatal sepsis can be problematic. Research suggests that many NICU nurses do not know how to accurately recognize early signs of sepsis. Nurses must be continuously educated on proper techniques required to prevent infections in neonates.

Beltempo, M., Lacroix, G., Cabot, M., Blais, R., & Piedboeuf, B. (2017). Association of nursing overtime, nurse staffing and unit occupancy with medical incidents and outcomes of very preterm infants. Journal of Perinatology, 38(2), 175–180.

Rittenschober-Böhm, J., Bibl, K., Schneider, M., Klasinc, R., Szerémy, P., Haidegger, T., . . . Assadian, O. (2020). The association between shift patterns and the quality of hand antisepsis in a neonatal intensive care unit: An observational study. International Journal of Nursing Studies, 112, 103686. doi:10.1016/j.ijnurstu.2020.103686

Tyer-Viola, L. A., Boettiger, M., & Hagan, J. (2017). Early Recognition of Neonatal Sepsis by Nurses. Journal of Obstetric, Gynecologic & Neonatal Nursing, 46(3), S50–S51.

Where is/are the setting(s) in which the problem is occurring? Describe community, county, city, state or hospital, other health care settings.

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