Use of A Patient Hand Hygiene Protocol to Reduce Hospital-Acquired Infections and Improve Nurses’ Hand Washing:
By Cherie Fox, RN, MSN, CCRN-CSC, Teresa Wavra, RN, MSN, CNS, CCRN, Diane Ash Drake, RN, PhD, Debbie Mulligan, RN, MSN, PHN, CIC, Yvonne Pacheco Bennett, RN, BSN, JD, CCRN, Carla Nelson, BSN, CIC, Peggy Kirkwood, RN, MSN, ACNPC, CHFN, AACC, Louise Jones, RN, MSN, CCRN, and Mary Kay Bader RN, MSN, CCNS
The given expertise of authors highlights many strengths and limitations. Based on the cited qualifications and affiliations, it can be said that all of them are well versed and have knowledge of health care system. The most important strength is that all of the authors are from the same background having expertise and qualification in the health care. Thus, it is easy to take any decision related to theory because everyone has knowledge of that particular field. However, some of them are nurses, and the others are ahead in the hierarchy. This showcase that there are chances that can lead to conflict of interests. It is possible that the voice of the nurse may be not heard or ignored. And since nurses are the one who works on the ground level and look after the patients, this is a major limitation. This can lead to bias in the result.
Hypothesis Of The Research Paper
The aim of the research paper is to find out whether the use of a patient hand hygiene protocol reduces the hospital acquired infection rates and improve nurses' hand washing compliance in an intensive care unit. Therefore, the null hypothesis set is that the patient hand hygiene protocol does not reduce the hospital acquired infection and not does not improve nurses' hand washing compliance. Whereas, the alternative hypothesis says that it does reduce the infection and improves nurses' hand washing compliance.
The significance of this hypothesis was felt by the authors. This was due to the increased mortality and morbidity of the patients due to hospital acquired infections. There was a large number of deaths observed in United States due to the hospital acquired infections. The patients who were critically ill were most affected and were at high risk due to the hospital acquired infection. The registered nurses are the ones who take care of the patients. They are the main health providers. Thus, the hypothesis also include to improve the nurses' hand washing compliance.
There was a lot of discussion on the hospital acquired infections. In fact, many steps were taken by the hospitals to reduce this infection and increase nurses' hand washing compliance. It was considered that increasing health care workers’ (HCW) hand washing practices can bring a change and will be proved effective. Many strategies were applied to increase the hand washing compliance by both patients and health care workers like the use of chlorhexidine gluconate (CHG) disinfectant. It was recommended that baths with CHG can improve the condition. Unfortunately, the adoption of CHG baths was introduced in few ICUs and not all. Also, it was found that nurses was patients hand only 14 per cent of the time when patients cannot move. There are many factors to the non compliance of hand washing practices. Some of them are attitude, lack of awareness of outcomes, social pressure, control, and prior life experiences.
There was an intended improvement of 90,000 preventable deaths associated with hospital acquired infection. The authors find gaps in the literature or research done. Thus, they attempted to use this patient hand hygiene protocol to check the reduction in hospital acquired infections and improvement in nurses' hand washing compliance.
The methodology used by the authors were to compare the rates (quantitative design) of hospital acquired infections and nurses' hand washing compliance before and after the implementation of protocol. There was a ten- week protocol phase period. The study was conducted in a 27-bed adult cardiovascular medical ICU at Mission Hospital in Mission Viejo, California, a 498-bed community hospital. During this phase-in period, the nurse were given training on how to keep hygiene and regularly wash their hands and keep sure to maintain the hygiene of their patients. Various reminders were given during this protocol period to ensure that proper steps are taken to prevent the hospital acquired infection. Also, medical record was made wherein the nurses have to fill the documents with yes or no to follow the instructions (qualitative design). The patients of the ICU, along with their families were also introduced with the protocol by the nurses.
The pre- experimental study design was made to compare annual (twelve months) rates of the two common hospital-acquired infections, central catheter–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI), and nurses’ hand-washing compliance measured before and during use of the protocol.
The study was conducted in a 27-bed adult cardiovascular medical ICU at Mission Hospital in Mission Viejo, California, a 498-bed community hospital. The diagnoses of patients admitted to this unit included medical diagnoses (50%), cardiac diagnoses including open heart surgery (34%-39%), and surgical diagnoses (12%-14%). The mean annual ICU daily census was 22.2 patients, with seasonal fluctuations ranging from 12 to 27 patients. Staffing was based on ratios and acuity with a ratio of 1 nurse to 2 patients in most cases.
The purpose of this quality improvement study was to answer two research questions:
1. Is the patient hand hygiene protocol associated with decreased CLABSI and CAUTI rates in the ICU?
2. Is the patient hand hygiene protocol associated with increased hand-washing compliance among ICU nurses?
Statistical analyses were conducted by using SPSS version 21. Rates of HAIs (both CAUTIs and CLABSIs) and nurses’ hand-washing compliance before and during implementation of the patient hand hygiene protocol were compared from two 12-month periods. A test was used to compare changes in hospital acquired infection rates and also changes in nurses’ hand-washing compliance rates. Significance was defined as a P less than .05. If P value was less than 0.05, then the hypothesis is considered to be statistically significant and the null hypothesis is rejected. Whereas, a P value more than 0.05 implies that the hypothesis is statistically insignificant and the null is not rejected.
The results tell us that there are changes observed after the implementation of protocol. These changes were favourable. We noticed a fall in the rates of CLABSI and CAUTI. Both hospital acquired infections were reduced after the use of protocol. But, these were statistically insignificant. That means there was not enough proof to reject the null hypothesis. The null hypothesis which says that patient hand hygiene protocol does not reduce the hospital acquired infection and nurses' hand washing compliance cannot be rejected. This was due to the P value. P value was more than five per cent. This implies that the results was statistically insignificant. However, it was noticed that the compliance of nurses hand washing before attending the patient increased. This implies that there was a shift of the nurses' focus from self protection to protection of patients.
Moreover, there was side effects of using CHG cleansing. Irritation in eyes were observed when patients touch their eyes before their hands became dry. Thus, there is a need in the further investigations to resist the use of CHG while using the protocol. Also, the methodology was not up to mark. Rather than observing before and after the use of protocol, a better design can be implemented. One of the suggestions is to create treatment and control group which the authors did not use. The creation of control and treatment groups can help to accurately find the changes from the implementation of protocol. This is done using the difference in difference method and thus the treatment effect is calculated.
Besides, there was a bias created by using this protocol in only one ICU rather than other institutions. Also, there was a fear of Hawthorne effect, which says that the nurses increase their compliance because they think that their actions are being observed. Thus, only during the time of protocol these improvements were seen. The demographics were also not been looked after before using the protocol. It is possible that the age, gender etc. Were different before and after the implementation of protocol. Therefore, seeing all these limitations of the paper, it is advised to correct all these while implementing the protocol in further studies in which experimental design is used.
Survey on Knowledge, Attitude and Hygiene Practice of Hands by Nursing Professionals
By Cynthia Angélica Ramos de Oliveira Dourado, Débora do Carmo da Costa Barros, Rafaela Vanessa Diogo de Vasconcelos, Alessandro Henrique da Silva Santos
The authors of this paper are either studying in the health care centres or are the professors or the registered nurse in the intensive care units. The strengths of the expertise of the authors are that they are all into the research sector where they can study more and can find out the required result for the research question. Whereas, on the other hand, there is a possibility that since there are no specialist of infection control or research scientist like infection control practitioner, the result will not be accurate as it could be under the guidance of specialists. This could lead to bias.
Objective of the research paper
The aim of this research paper is to find out the knowledge, attitude and hygiene practices of hands of nursing professionals within an intensive care unit. The null hypothesis set in this research paper is that there is no difference in the knowledge, attitude and practice of hand washing of nurse professionals in both hospitals A and B.
The significance of this paper is felt by the authors. The motivation behind the survey is the increase in the infections caused by the nurse professionals or health care workers. It was observed that before attending the patients, they do not care and practice hand washing. Infection Related to Healthcare (IRAS) is due to the acquisition of pathogenic microorganism through invasive, therapeutic or diagnostic procedures performed without technical rigor at any level of care by health professionals. This is an important health problem and was established when the first hospital was made. Therefore, there was a need to increase the hygiene practices of the health care workers especially, the nurse professionals because they come in contact with the patients frequently.
There was a spread of infection (IRAS) and that was leading to the mortality and morbidity of the patients. There was an increase threat of this infection in the intensive care units (ICUs) as the patients were critically ill. Worldwide, ten per cent of patients in hospitals are severely affected by these infections. It was observed on a daily basis in Brazil. Patients with this infection was rising in an increasing order. It was observed that thirty per cent of the patients in intensive care units were affected by at least one infection if this type.
There is a growing need of taking precautionary measures to stop this infection. These measures include washing hands before and after attending the patients with alcohol, disinfecting their hands after any operation done, use of gloves if there is any risk of body fluid contamination, use of apron and many others. As, nurses are the health care workers who can take these measures to stop the infection, this paper is aimed to check their knowledge, attitude and hand washing practices.
The data collected is a cross-sectional data. The analytical study is done with 131 nursing professionals from six intensive care units of two university hospitals in Pernambuco, developed from the KAP survey instrument - Knowledge, Attitudes, and Practices in Health. Frequency distributions, the central tendency and dispersion measures as well as the normality tests were used for data analysis. The reference is taken as five per cent level of confidence interval.
The questionnaire used for data collection was elaborated and validated in Senna's dissertation work in 2010, which carried out this same segment of study in two highly complex cardiological hospitals located in the city of Rio de Janeiro. The questionnaire is a self-administered instrument, standardized to measure three dimensions known as Knowledge, Attitude and Practice, which contain specific and pre- corded questions for each axis, where 40 questions are related to Knowledge, 22 to Attitude and 27 to Practice. Also, there are 17 questions regarding the socio- demographic and professional aspects of the study participants.
A bank was built in the EPI INFO program, version 3.5.2 to analyse the data, which was exported to the SPSS software, version 18, where the statistical analysis and treatment of the data was performed. The percentage frequencies were calculated, and the respective frequency distributions were constructed to evaluate the distribution of personal factors, professional training, and work experience.
The statistics were calculated in the evaluation of the knowledge score, attitude and practice of the professionals: minimum, maximum, average and standard deviation. Furthermore, the confidence interval (CI) was calculated for the estimated means. The Kolmogorov-Smirnov test was applied to evaluate the normality of the scores of knowledge, attitude, and practice.
In cases where the normality of the score was indicated, the t-student and ANOVA tests were applied according to the need of analysis, to compare knowledge of attitude and practice among interest groups, and, in cases where normality was not indicated, the Mann-Whitney and Kruskal-Wallis test were used. All conclusions were based on the significance level of 5%.
From the analysis of the data, many inferences came forward and are shown in the tables (Table 1- 4) in the research paper. In all the tables mean and standard deviation of different variables are calculated. From Table 1, it is shown that there is no significant difference between average knowledge of professionals of hospital A and hospital B. This means that both the hospitals are similar with respect of knowledge in the professionals. In table 2, the mean and standard deviation of attitudes between the professionals of both hospitals are estimated. With the help of P value (0.847) which is more than 0.0.05 which means that there is no difference in the mean attitudes of professionals in hospital A and hospital B.
Further, it implies that the attitude of professionals of both hospitals are similar. In table 3, average and standard deviation of practice scores are evaluated for both hospitals. In the comparison of the average scores of both hospitals, it was observed that the hospital B had higher mean practice score than hospital A. Also, the P value turned out to be 0.031 which is less than 0.05. This means the hypothesis is statistically significant. Further, it implies that the hospitals are different with respect to the practice scores. In table 4, descriptive analysis is done of the knowledge, attitude and practice scores of both hospitals.
It is verified that the evaluated professionals presented a higher level of Attitude 88% of the total of the scale, followed by Knowledge 77.4% and Practice 65.6% on average. Thus, with the help of P value which is less than 0.001, we can say that there is a difference in the knowledge that professionals acquire, the attitude which they consider correct and the practice they do. In fact, the professionals show higher attitude, followed by knowledge and the last is the practice.
However, hand hygiene is considered as an easy and significant practice in the prevention and control of nosocomial infections. But it has a decrease in satisfactory indices when associated with development in practice. The main finding of the paper is demonstrated in table 4. It tells us that Practice, which is one of the most important part to reduce the infection caused by the health care workers, has obtained the lowest indices in the Knowledge, Attitude and Practice (KAP) strategies. This is really a major problem because despite the fact that the professionals have great knowledge, they do not practice hand washing compliance. They do not adhere to the healthy practices which should be opted in the health care units. The professionals should rethink upon the practices and try to improve it.
From the critical analysis of the two term papers, it is observed that the practice of the health care workers is to be improved. The threat in the hospital acquired infection can be reduced with proper implementation of hand washing practices and other preventive practices by the nursing professionals. Also, repetitive supervision can be done to look after the health care workers so that the practices are implemented.
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