| Course | NU 700 Knowledge for Nursing Practice |
|---|---|
| Unit | Unit 5 |
| Paper type | Evidence appraisal paper |
| Length | About 1,030 words, 6 pages |
| Format | APA 7 student paper |
| School | Herzing University |
| Program | MSN |
| Updated | October 2026 |
Free sample paper for NU 700 Unit 5
Appraising Three Trials of Chlorhexidine Bathing to Prevent ICU Infections for a Community Hospital Decision
Student Name
Department of Nursing, Herzing University
NU 700: Knowledge for Nursing Practice
Instructor Name
February 17, 2026
Appraising Three Trials of Chlorhexidine Bathing to Prevent ICU Infections for a Community Hospital Decision
Purpose, Tool, and Hierarchy
A 16-bed intensive care unit in a community hospital is considering daily bathing with chlorhexidine gluconate cloths for all patients to reduce hospital-acquired infections. Three frequently cited trials were gathered earlier; this paper judges each one. The Johns Hopkins Evidence-Based Practice model is used for both the level of evidence and the quality rating: Level I is an experimental study or a randomized controlled trial, and quality is rated A (high), B (good), or C (low or major flaws) based on consistency, sample, control, and the plausibility of the conclusions (Dang et al., 2022). Each study is appraised in the same order: design and level, sample and attrition, intervention and outcome measurement, threats to validity, quality rating, and applicability to the community hospital.
Study 1: Climo et al. (2013)
Design and level: cluster-randomized crossover trial without blinding, run in nine intensive care and marrow transplant units across six hospitals, each unit randomized to six months of chlorhexidine bathing and six months of nonantimicrobial washcloths. Level I.
Sample and attrition: 7,727 patients. Because units, not individuals, were randomized, attrition in the usual sense is less relevant; the relevant concern is whether patient mix differed between periods, which the authors examined.
Measurement: the primary outcome was acquisition of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on surveillance cultures, and the secondary outcome was hospital-acquired bloodstream infection. Surveillance cultures are objective and were collected systematically, which strengthens the primary outcome.
Findings and threats: bathing reduced the rate of multidrug-resistant organism acquisition by 23% and hospital-acquired bloodstream infections by 28% (Climo et al., 2013). Threats: nurses and patients knew which washcloths were in use; bloodstream infection definitions can be applied differently when the assessor knows the period; and baseline infection rates in these academic units may be higher than in smaller hospitals. Quality: A, with a caveat about the unmasked secondary outcome.
Applicability: several units were academic and specialized, with patients at higher baseline risk. The finding may overstate the absolute benefit in a community ICU with lower baseline rates.
Study 2: Noto et al. (2015)
Design and level: pragmatic, cluster-randomized crossover trial in five adult ICUs at one academic medical center, with units alternating between chlorhexidine and nonantimicrobial cloths over 10-week periods, with washout periods. Level I.
Sample and attrition: 9,340 patients. Large and consecutive, with few exclusions, which supports generalizability within the institution.
Measurement: a composite of central line-associated bloodstream infection, catheter-associated urinary tract infection, ventilator-associated pneumonia, and Clostridioides difficile infection, determined by infection preventionists using standard definitions. The composite includes outcomes that chlorhexidine is less plausibly expected to affect, such as C. difficile, which could dilute a real effect on bloodstream infection.
Findings and threats: chlorhexidine bathing did not reduce the composite outcome of health care-associated infections (Noto et al., 2015). Threats: a single center; short crossover periods, with possible carryover; low baseline infection rates, which reduce the power to detect a difference; and a composite outcome that may have masked an effect on one component. Quality: A.
Applicability: a single academic center with low baseline rates; the low baseline is closer to a community ICU than Study 1, which makes this null finding directly relevant to the decision.
Study 3: Huang et al. (2013)
Design and level: pragmatic cluster-randomized trial in 74 ICUs in 43 hospitals, comparing screening and isolation, targeted decolonization, and universal decolonization with chlorhexidine bathing plus intranasal mupirocin. Level I.
Sample: 74,256 patients in the intervention period, across community and academic hospitals within one hospital system. Measurement: MRSA clinical cultures and bloodstream infections from any pathogen, identified from microbiology data, an objective source.
Findings and threats: universal decolonization reduced MRSA clinical isolates by 37% and bloodstream infections from any pathogen by 44% compared with screening and isolation (Huang et al., 2013). Threat: the intervention combined chlorhexidine with mupirocin, so the effect cannot be attributed to chlorhexidine bathing alone. Quality: A.
Applicability: the strongest applicability of the three, because the setting included community hospitals similar to ours; but it tests a bundle, not the single intervention under consideration.
The Set, Judged Together
All three are Level I, high-quality trials, and they do not agree. The two trials with higher baseline infection rates or a combined intervention showed benefit, while the pragmatic trial in low-baseline ICUs did not. The likely explanation is baseline risk: where infection rates are already low, the absolute benefit of chlorhexidine bathing is smaller and harder to detect. For the community hospital, the decision depends on its own baseline rates; if its central line infection rate is low, the evidence supports chlorhexidine bathing less strongly than the headline findings of the first trial suggest, and the more applicable evidence is for the combined decolonization bundle.
What the Appraisal Means for the Decision
The appraisal changes the question the unit should be asking. Instead of asking whether chlorhexidine bathing works, which the evidence answers with a qualified yes in higher-risk settings, the unit should ask what its own baseline is and which outcome it most wants to change. The first step is therefore local data: the unit's central line-associated bloodstream infection rate, multidrug-resistant organism acquisition rate, and hand hygiene and line maintenance compliance over the past two years. If the bloodstream infection rate is already near zero and line care compliance is high, the expected benefit of adding universal bathing is small and the cost, skin reactions, and the theoretical risk of promoting chlorhexidine resistance weigh more heavily. If the rate is above the national benchmark, the evidence from the first and third trials becomes more applicable.
The appraisal also identifies what the set cannot tell the unit. None of the three trials reports patient-centered outcomes such as skin integrity or patient comfort in detail, none examines adherence to bathing in a unit staffed like ours, and none was conducted in a small ICU without infection prevention staff dedicated to the unit. A pilot with a clear measure of bathing compliance and skin reactions would fill part of that gap, and the unit's infection preventionist has agreed to provide baseline data before the proposal goes to the practice council.
References
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.
Huang, S. S., Septimus, E., Kleinman, K., Moody, J., Hickok, J., Avery, T. R., Lankiewicz, J., Gombosev, A., Terpstra, L., Hartford, F., Hayden, M. K., Jernigan, J. A., Weinstein, R. A., Fraser, V. J., Haffenreffer, K., Cui, E., Kaganov, R. E., Lolans, K., Perlin, J. B., & Platt, R. (2013). Targeted versus universal decolonization to prevent ICU infection. New England Journal of Medicine, 368(24), 2255-2265. https://doi.org/10.1056/NEJMoa1207290
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
What the NU 700 Unit 5 instructions ask for
The Unit 5 assignment asks you to critically appraise research studies tied to your PICO question with an established appraisal instrument. Expect to state the purpose and name the tool, then evaluate each study for design, level of evidence, sample, methods, results and quality. Many sections ask you to judge the body of evidence as a whole and say whether it supports a practice change. Some require a set number of studies, often three, carried forward from your literature matrix. Your section may require the Johns Hopkins model or let you pick another tool. You may also be asked to address applicability to your setting, which is different from quality. Keep each appraisal in the same order so the studies can be compared directly.
How this NU 700 Unit 5 example is built
The paper opens with the decision the unit faces and names the Johns Hopkins model as the appraisal tool, with a sentence on how it separates level from quality. Each trial then gets its own section with the same labels: design and level, sample and setting, intervention, findings, and quality rating with reasons. Climo's trial is rated high quality despite the lack of blinding, and the paper explains why. Noto's null result is treated seriously rather than dismissed. Huang's trial is flagged because chlorhexidine was paired with mupirocin, so its effect cannot be credited to bathing alone. The set section compares baseline infection rates across the three. The decision section turns the question toward the unit's own rates and supply costs, which the trials cannot answer for it.
NU 700 Unit 5 rubric: what full points look like
Herzing appraisal rubrics generally award points for naming and using an appraisal tool, accurate appraisal of each study, synthesis of the evidence, a recommendation, and writing. Tool use earns full points when the level and quality ratings follow the tool's definitions rather than the student's impression. Each study's appraisal is checked for correct design identification, honest strengths and weaknesses, and a rating with reasons. Synthesis points reward papers that explain why studies agree or disagree instead of listing them. The recommendation criterion asks whether the conclusion follows from the appraised evidence and fits the setting. Writing and APA 7 make up the last criterion, including citations for each study and the tool itself. Consistent subheadings for each study make all of these easier to find and credit.
NU 700 Unit 5 help before you submit
The usual point loss on Unit 5 is treating level and quality as the same thing, so every randomized trial is called strong without looking at how it was run. Students also skip weaknesses in studies that support their preferred answer. A null finding is often explained away when it deserves the same appraisal as positive ones. Another problem is appraising the abstract instead of the full article, which misses details like co-interventions or crossover washouts. Recommendations that ignore the setting, such as a community hospital with lower baseline rates, read as generic. If the tool asks for a quality grade, give one in its terms, A, B or C, not your own scale. Finally, include the appraisal tool's citation, which many students forget.
Get a NU 700 Unit 5 example written to your instructions
Send the Unit 5 instructions and the rubric from your NU 700 classroom, plus the studies you have been asked to appraise and any tool your instructor named. We write a custom example against those instructions, with each study judged the same way and applicability stated, and return it in 24 to 48 hours. The first one is free.
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NU 700 Unit 5 questions, answered
Which appraisal tool should I use?
Use whichever your instructions or your program name, since many sections specify one. Where the choice is open, pick a published instrument matched to the design in front of you and cite it, then apply the same instrument to every study of that design. Switching tools between studies makes the ratings incomparable, which is the one thing an appraisal has to avoid.
Is a level of evidence the same as quality?
No, and conflating them is a common loss. Level describes the design and where it sits in a hierarchy. Quality describes how well that design was carried out: allocation, blinding where possible, attrition, measurement and analysis. A well conducted cohort study can be more trustworthy in practice than a small trial that lost a third of its participants before the end.
Can qualitative studies be appraised in this piece?
Yes, provided the instrument fits. Qualitative work is judged on credibility, the fit between question and method, sampling logic, how analysis was documented and whether the interpretation is traceable to the data. Applying trial criteria produces complaints about sample size that miss the point entirely. Check whether your instructions allow mixed designs before building the set.
Where can I find a free NU 700 Unit 5 sample paper?
The complete NU 700 Unit 5 chlorhexidine appraisal is on this page at no cost, with each trial rated and the set judged together. A custom appraisal can be prepared from your own three studies and whichever tool your section names.
Can three high-quality trials disagree with each other?
Yes. Strong trials can reach different results because their settings, baseline rates or interventions differ. In this sample two trials showed benefit and one did not, and the difference tracks the units' starting infection rates and the added mupirocin in the largest trial.