Critique - Research Proposal Example

Research Critique Introduction: The article which has been chosen for a critical analysis Lim, W; Holinski, P; Devereaux, P.J; McDonald, E; Clarke, F; Qusmaq, I; Terrenato, I; Schunemann, H; Crowther, M & Cook, D. 2008, ‘Detecting myocardial infarction in critical illness using screening troponin measurements and ECG recordings’, Critical Care, [Online] Available at: http://ccforum.com/content/12/2/r36 (Accessed April 25, 2006). 2. Rationale for Choice: There are three reasons for selecting this article. The first is that topic is relevant to my area of nursing, as I work in a critical care unit. The second is that cardiovascular problems like myocardial infarction are a frequent occurrence. Such a perspective finds support from Katz, et al, 2007, who point out that many of the critical care unit patients are likely to be those with cardiovascular co-morbidities that lead to many cardiac events like myocardial infarction during their stay in the critical care. Finally, myocardial infarction can increase the mortality rate in critical care units and the means to identify the onset of myocardial infarction at an early stage reduce patient care and quality of care concerns. 3. Purpose of Study: The purpose of the study is to determine whether screening of patients admitted to intensive care units using cardiac troponin and electrocardiogram measurements shows incidence of elevated cardiac troponin and myocardial infarction and to ascertain whether these findings have an impact on the prognosis of the patient. The purpose of the study is narrow, not vague and an achievable one. This gives relevance for the study. In addition, through this prospective screening study there is an attempt to identify a means to early identification of the probability of an episode of myocardial infarction and through that make for a better prognosis of the patient. 4. Literature Review: Elevation in serum troponin levels provides a sensitive indication of cardiac injury, as troponin is specific to cardiac muscles (Minkin, et al, 2005). Troponins I and T make up two of the members of the three member protein complex that has an essential role to play in the contraction of a striated or cardiac muscle. Cardiac proteins differ in their amino acid sequence from skeletal muscle proteins and this is the reason for the specificity of plasma troponin in providing a reliable index of myocardial injury (Boulier, et al, 2004). According to Demir, et al, 2007, elevated cardiac troponin levels are highly sensitive and provide specific indication of myocardial cell death. Patients likely to suffer from myocardial infarction can be identified early through an assessment of elevated cardiac troponin levels. It is based on this available evidence that the authors have arrived at the hypothesis that screening of patients for elevated cardiac troponin levels combined with the electrocardiograms provides an insight into the incidence of myocardial infarction in critically ill patients and through that offer a better prognosis for these critically ill patients. 5. Methods, Procedures and Ethical Aspects: A qualitative methodology has been employed by the authors with an experimental research design, through the screening of the participants using the two interventions of electrocardiograms and serum tests for elevated serum levels. In trying to ascertain the impact of interventions on a chosen variable, the experimental research design is well suited to provide answers towards the purpose of a study (Ruanne, 2005). This makes the chosen research method and design suited for the purposes of this study. The fifteen-bed university-affiliated medical and surgical combined intensive care unit was the setting for the study, with all patients that were admitted into the intensive care unit during a two-month period taken as subjects for the study. The setting is suitable as the necessary screening facilities were available. However, the period needed to be extended to at least six months to increase the validity of the findings of the study. Assays of cardiac troponin levels and electrocardiograms were taken at the time of admission and then daily during the first week, subsequently on alternate months and then on a weekly basis, up to the discharge or demise of the patient. Skilled research assistants were used for the purpose of these interventions. In this manner the study has made use of extensive screening coverage towards the findings for its study. In addition to this data, additional data collected from the patient medical chart, the ICU computerized clinical information system and the hospital laboratory system in case report forms and then entered into an Excel program for statistical analysis, making for effective data collection and collation. The main constituents of the statistical analysis consisted of the comparing of continuous variables employing the Kruskall-Wallis non-parametric tests and the Mann-Whitney paired test for the purpose of exploring the differences in groups. Categorical variables were analyzed using Pearson Chi-square tests or Fisher’s exact tests depending on appropriateness of the test. The statistical tests employed are satisfactory towards providing the required statistical analysis and findings of the study (Grafen & Hails, 2003). Ethical considerations have been covered by the obtaining deferred consent from a family member soon after admission into the intensive care unit and where consent was denied, data of the cardiac troponin levels and electrocardiograms as ordered by the intensive care unit team was used. Approval was received from the institutional Research Ethics Board prior to the study. However, the study is silent on the methods employed to ensure patient confidentiality. 6. Results and Discussion: Screening investigations helped to detect more myocardial infarction than through clinical diagnosis alone. Yet the length of stay of the patients in the intensive care unit and the hospital and the mortality rates remained the same as was experienced with patients whose myocardial infarction was detected by the ICU team and by screening. The study employs a novel screening method for myocardial infarction in the dual use of elevated cardiac troponin markers and electrocardiograms. The use of electrocardiograms in addition in the screening program is understandable, as according to Porela et al, 2000, in spite of the advances of new myocardial infraction markers like creatine kinase MB isoenzyme concentration and cardiac troponins, the electrocardiogram remains the cornerstone in the diagnosis of myocardial infarction and in the therapeutic decisions. Elevated cardiac troponin levels are an indication for adverse prognosis among the critically ill patients and the study found that these elevated cardiac troponin levels were associated with enhanced hospital mortality rates. The study attributes this feature of enhanced cardiac troponin levels to cardiac troponin being releases only when there is damage to myocardial cells increasing the risk of death. Such a contention of the authors finds support from Minkin, et al, 2005, Boulier, et al, 2004 and Demir, et al, 2007. The authors admit that for a greater validity of the study and to overcome the variability of the association of elevated cardiac troponins in critically ill patients with mortality and other adverse outcomes a larger sample size is required. Not being able to really establish any real association of screening using cardiac troponin levels and electrocardiograms in the prognosis of critically ill patients, the authors call for further studies to validate it. 7. Overall Concerns: Screening tests using both cardiac troponin levels and electrocardiograms in critically ill patients during their stay in intensive care units will be expensive. Given the state of rising costs of diagnosis, treatment and medications, there is concern on the ability of patients and health authorities to meet these escalating costs. There needs to be definite justification through reduced mortality rates or in reduced stay in the intensive care units or hospitals for such screening tests to become a viable proposition. This study fails to establish this definite justification. In addition the Minkin, et al, 2005, concluded that there was no benefit from routine cardiac troponin level tests in patients admitted to medical intensive care units, when clinical diagnosis does not indicate a myocardial infarction event. Given the lack of definite benefits that ensue from the use of cardiac troponin and electrocardiogram screening in critically ill patients the use of such screening tests need to be considered only when further studies establish definite benefits in the prognosis of the critically ill patients. Literary References Boulier, A; Jaussent, I; Terrier, N; Maurice, F; Rivory, J; Chalabi, L; Boularan, A; Delcourt, C; Dupuy, A; Canaid, B. & Cristol, J. (2004), ‘Measurement of circulating troponin Ic enhances the prognostic value of C-reactive protein in haemodialysis patients’, Nephrology Dialysis Transplantation, vol.19, no.9, pp. 2313-2318. Demir, M; Kanadas, M; Akpinar, O; Donmez, Y; Avkargullari, M; Alhan, C; Inal, T; San, M; Usal, A & Demirtas, M. 2007, ‘Cardiac Troponin T as a Prognostic Marker in Patients With Heart Failure: A 3-Year Outcome Study’, Angiology, vol.58, no.5, pp. 603-609. Grafen, A. & Hails, R. 2003, ‘Modern Statistics for Life Sciences’, Oxford: Oxford University Press. Katz, J.N; Turer, T.E & Becker, C.R. 2007, ‘Cardiology and the Critical Care Crisis: A Perspective’, Journal of the American College of Cardiology, vol.49, no.12, pp.1279-1282. Lim, W; Holinski, P; Devereaux, P.J; McDonald, E; Clarke, F; Qusmaq, I; Terrenato, I; Schunemann, H; Crowther, M & Cook, D. 2008, ‘Detecting myocardial infarction in critical illness using screening troponin measurements and ECG recordings’, Critical Care, [Online] Available at: http://ccforum.com/content/12/2/r36 (Accessed April 25, 2006). Minkin, E; Cotiga, D; Noack, S; Dobrescu, A; Homel, P & Shapiro, M. J. 2005, ‘Use of Admission Troponin in Critically Ill Medical Patients’, Journal of Intensive Care Medicine, Porela, P; Pulkki, K; Helenius, H; Antila, J.K; Petersen, K; Wacker, M; & Voippio-Pulkki, L. 2000, ‘Prediction of Short-Term Outcome in Patients With Suspected Myocardial Infarction’, Annals of Emergency Medicine, vol.35, no.5, pp.413-420. Ruane, M. J. 2005, ‘Essentials of Research Methods: A Guide to Social Science Research’, Massachusetts: Blackwell Publishing. Read More