NURS 340 Evidence-Based Practice

Evidence Based Practice Research: In this task, I will identify a healthcare problem and develop a question that can be informed by evidence. Identify a single intervention and then search for five research articles (see attachment) and two non-research articles (see attachment) that support the intervention.
P(problem): Hand Hygiene Compliance in Health Care

I(Intervention): Enhance Theory Education on Hand Hygiene Seminar

C(Comparison): Standard Practice Care

O(Outcome):Increase Hand Hygiene Compliance Measurable Outcome, after 3 months of theory education on hand hygiene there will be 30% increase in hand hygiene compliance.

PICO question: Among health care environment, does enhance theory education on hand hygiene seminar increase hand hygiene compliance as compared to current standard practice?

Problem:

Hand hygiene is a general term which can be used for the activities related to the hand cleansing. World Health Organization (WHO) published guidelines on hand hygiene which comprises of scientific data on hand hygiene rationale and practices in health care. Hand hygiene is required in five instances like prior to touching to the patient, prior to carrying out aseptic and clean procedures, at the time of risk of exposure to body fluids, after touching patient and after touching patient’s belongings and surroundings. Dynamic behavioural change is required for maintaining hand hygiene. Infection prevention and control programme should be implemented through healthcare related training and education for maintaining hand hygiene. All the healthcare workers should incorporate hand hygiene as the integral part of their practice. However, it was evident that medical and nursing students are shortfall in education about hand hygiene. Education about hand hygiene should be initiated from the first year of their curricula (Srigley et al., 2016).

Patients and healthcare providers are more susceptible to the methicillin resistant Staphylococcus Aureus (MRSA). Precautions should be taken during hand hygiene because frequent hand wash is associated with certain adverse events like dryness and irritation. Successful implementation of the system change in the hospital can be achieved by education to the staff members. It is evident that less support from the management and insufficient resources for hand hygiene are the main hurdles for implementing hand hygiene. Scarcity of resources is mainly evident in the developing countries. Behavioural changes among healthcare professionals are required for implementing hand hygiene. Education, awareness and training can bring positive behavioural changes among healthcare professionals. Lack of adherence to the hand hygiene policy implementation is one of the main reasons identified for increased infections through hands. Continuous monitoring for successful implementation of hand hygiene is difficult because observation of hand hygiene is associated with error and bias. There are more chances of false positive results during evaluation of hand hygiene implementation programme. There is no validated method available for monitoring hand hygiene, hence surrogate methods should be used to monitor it. It is necessary to develop robust method for monitoring hand hygiene. It is difficult to get direct and observable results in case of hand hygiene (Goldberg, 2017).

Significance of the problem:

Cleaning of hands can be helpful in preventing spread of microorganisms including those are resistant to antibiotics. It is evident that healthcare professionals clean their hands approximately 50 % of the times as compared to its requirement. Approximately 0.4 % patients get infected due to healthcare related microorganisms. Thousands of people die daily due to infection spread through hand at the time of receiving healthcare services. During healthcare practices, hands are the most important route of transmission of microorganisms. In developed countries, approximately 7 % hospitalised patients and 20 % intensive care unit patients encounter hospital related infections. In developing countries approximately 10 % hospitalised patient and 30 % intensive care unit patients encounter hospital related infections.

There is measurable difference among developed and developing countries in terms of infection due to hands. Patients in the developing countries are more susceptible for infection as compared to the developing countries. Healthcare providers need to be in constant touch with the patients which can spread infections to other people. Hand contamination can spread infection in both direct and indirect way and it is more prevalent in the intensive care unit and hemodialysis unit. Most of the healthcare workers are following hand decontamination procedures, however it is evident that there are very less chances of successful decontamination of the hand. Ideal method for the hand decontamination can be provided through educational and training programme. Hand hygiene is more significant in healthcare facility because in healthcare facility hand infection can affect patient health. Health care providers need to use disinfectant for their hands for at least 100 times in a 12 hrs shift. Selection of disinfectant is also important for hand hygiene because alcohol based disinfectants are not useful for few microorganisms like C. difficile. It is evident that there is progress in promotion of education and training for controlling hand associated infection hygiene however, there is less progress in monitoring hand hygiene and behavioural changes for improving hand hygiene. Patients can carry microorganisms to larger population, hence hand hygiene should be maintained for all type of patients (Winship, and McClunie-Trust, 2016).

Current practice :

Hand hygiene can be maintained by implementing multi-modal strategies. Hand hygiene can be maintained by promoting its importance. It can be achieved through in-service education, information leaflets, workshops and lectures. Hand hygiene adherence for the healthcare staff should be maintained and rewards should be given to the staff with highest adherence rate for hand hygiene. The Occupational Safety and Health Administration (OSHA) guidelines stated to wear gloves during the all the activities related to the patients care. It is evident that freshly applied nail polish can prevent growth of microorganisms, hence prior to nursing intervention nail polish can be applied. National policies and plans should be implemented. Facility based guidelines and laws should be prepared for maintaining hand hygiene and these should be strictly implemented. Management of healthcare facility should allocate special budget to prevent hand originated infection. Surveillance of resistant microorganisms should be improved. Alcohol based hand-rub should be provided to all the health workers at the place of practice. There should be monitoring and feedback on compliance of hand hygiene. Visual reminders about hand hygiene should be displayed at the workplace. Organisational culture should be created for maintaining hand hygiene at the workplace (Winship, and McClunie-Trust, 2016).     

Impact:

Hand hygiene education programme would be helpful in bringing behavioural changes among healthcare staff. Education about the hand hygiene can improve quality standard of the healthcare facility. It would be helpful in improving overall healthcare services to the patients. It would be helpful in reducing hospital acquired and blood borne infections. It would be helpful in improving ranking of the healthcare facilities as compared to other competitive healthcare facilities. It would also be helpful in developing healthy and safety culture in the facility. Hence, preferences of the patients for the hospital would be increased.  Along with the health impact, hand hygiene can also affect financial condition of patient and hospital. Catheter associated infection like methicillin-resistant Staphylococcus aureus (MRSA) may cost upto US$ 38 000 per episode. Infections due to infected hand can lead to readmissions to the hospital. It can lead to financial burden both to hospitals and to the patient. Hospital need to make separate arrangement for the infected patients, which can have extra financial burden on the hospital. It would be helpful in developing protocols for hand hygeine and standardising the methods for hand hygiene. It would also reduce risk of infection to the healthcare workers, hence it would be helpful in improving productivity of the organisation. Implementation of hand hygiene practices would also be helpful in improving overall infection control strategy of the hospital.  Education programme would also be useful in developing leadership qualities for infection control and monitoring staff for implementing hand hygiene. It would be helpful in performing audit of hand hygiene and getting feedback for its implementation. It facilitates sustainable changes for implementing hand hygiene programme in the hospital (Srigley et al., 2016).   

PICO Table 

PICO question: Among health care environment, does enhance theory education on hand hygiene seminar increase hand hygiene compliance as compared to current standard practice?  

Articles related to hand hygiene interventions and education were searched. Hand hygiene interventions for healthcare staff were selected. Interventions were selected which were directed towards prevention of spread of infection to patients. Comparators in the interventions were either placebo or comparison among standard handwashing procedure with soap and different hand sanitizers. Educational programme for hand hygiene carried out at hospital facilities for the healthcare staff were selected. Targeted outcomes for the selection of the articles were respiratory tract infection, gastrointestinal tract infection, absenteeism rate, hospital readmissions, changes in behaviour, attitude, belief and knowledge of healthcare staff. More focus was given to healthcare staff outcome.

Key words for search strategy were divided in three classes like hand hygiene, healthcare facilities and study type. Date restrictions were  not applied however, language for articles was restricted to English. Data from the studies was extracted by using a standard template. Extracted data comprise of study details; intervention description, study recruitment, random allocation, study baseline data, follow-up,  process evaluation, outcomes and analysis. Following were the key words used for the search strategy : handwashing or hand washing, hand or hands, health education, health education and hand or hands, hand or hands hygiene, hand or hands and cleansing or cleaning, hand antisepsis, hand or hands disinfect, communicable disease control, communicable disease control and hand or hands, infection control and hand or hands, soap or soaps, soap or soaps and hand or hands, alcohol gel, anti-microbial gel, disinfectant gel, sanitizer, infection control and randomized controlled trial or infection control and controlled clinical trial, hand hygiene intervention or hand hygiene experiment, hand hygiene and nursing research or clinical nursing research or nursing evaluation research or nursing methodology research.

Search strategy was applied under four categories like identification, screening, eligibility and inclusion. 6256 articles were found in the electronic database searches in the identification step. These 6256 articles comprise of research articles, editorials and review articles. Information in these articles comprise of research evidence, quality improvement, national and international practice guidelines, WHO guidelines and expert opinion. From these 6256 articles, 1868 duplicate articles were removed. After removing duplicate articles, 4388 articles were screened for eligibility. Out of 4388 articles, 4122 articles were excluded based on the title of the article. These articles were removed because these were editorials, guidelines and expert opinion. Remaining 266 articles were screened for abstracts. These remaining articles comprise of randomised controlled trials and informative review articles. Out of these 266 abstracts, 212 abstracts were excluded. Remaining 54 articles were included in the full paper screening. Out of these 54 full text articles, 47 were excluded and finally 5 research articles and 2 non-research articles were selected. 

Research article : Shen et al., (2017), implemented quasi experimental study using questionaries’ to evaluate implementation of WHO multimodal hand hygiene strategy. Hand hygiene multimodal strategy was implemented comprising of different factors like environmental, individual and management. Hand hygiene compliance and correctness of the health workers for following hand hygiene were the evaluated outcomes in this research. This study was conducted in the hospital of traditional Chinese medicine. 553 participants were participated in this study.  After implementation of the multimodal strategy, there was statistically significant improvement in the compliance and correctness of hand hygiene as compared to the baseline. Compliance was met for all other criterias except “after body fluid exposure risk” and “after touching patient surroundings”’. Compliance was more for doctors as compared to the nurses and other health workers.    

Research article : O’Donoghue et al., (2016), implemented quasi experimental study to evaluate educational programme for hand hygiene. Questionnaires comprised of knowledge and attitude of healthcare professionals about hand hygiene. This study was implemented in the radiography department. 76 radiographers, 17 nurses, and 9 healthcare assistants were participated in this study. Educational intervention was provided for the duration of 2 months in the form of talks and visual aids. Hand hygiene compliance was observed for 3 weeks for all these participants. Educational intervention programme proved useful in improving hand hygiene compliance by approximately 50 % as compared to the compliance prior to the educational intervention.

Non - Research article : Whitcomb, (2014) implemented quality improvement programme with the objective to bring BSN students of school of nursing with hospital’s target of 90 % hand hygiene compliance. Data was collected in the form of direct observations and missed opportunities. From the study, it is evident that implementation of multidimensional quality improvement programme can be helpful in improving hand hygiene quality of nursing school students.

Non - Research article : Glodberg, (2017) focused on guidelines of hand hygiene. Association of periOperative Registered Nurses (AORN) guidelines give information about the hand hygiene, surgical hand antisepsis, nail polish, artificial nails, and skin care. According to these guidelines perioperative personal make aware of the hand hygiene and surgical hand antisepsis. Patients undergoing surgery and invasive procedure might be at higher risk of infection and they come in close contact with the perioperative nurses. Hence, perioperative nurse should be aware if these guidelines, implement it and incorporate these guidelines while preparing policies and procedures for hand hygiene.

Evidence matrix :

Hand hygiene compliance should be improved to implement hand hygiene practice in the hospital. The rate of compliance with HH improved from 66.27% at baseline to 80.53% after intervention (Shen et al., 2017). Before the intervention, overall hand hygiene compliance was low (28.9 %). Post-intervention, compliance with hand hygiene increased to 51.4 % (O’Donoghue et al., 2016). After intervention, the hand hygiene compliance rate improved significantly in pediatrics (24.1% to 43.7%; P<0.001), internal medicine (5.2% to 18.5%; P<0.001), and obstetrics-gynecology (10.1% to 20.5%; P<0.001) (Santosaningsih et al., 2017). The components of the interventions were similar to the WHO multimodal approach for improving healthcare woekrs hadn hygiene compliance, including education,, reminders, audit and feedback and provision for hand hygiene products (Srigley et al., 2015). It is evident that  that hand hygiene compliance among nurses is improving slowly, it is evident that further improvement could be made.  (Winship and McClunie-Trust, 2016).

Three stakeholders like nurse, nurse manager and surgeon should be involved in the decision-making process to implement the change. These three stakeholders should be involved in implementing hand hygiene in the hospital. These three stakeholders should be selected because they are mainly responsible for maintaining hand hygiene during surgery. Surgery is the most potential medical practice mainly responsible for susceptibility to infection. Involvement of these stakeholders in implementing hand hygiene can result in the sustained implementation of the practice because they would follow the practice on regular basis. nurse, nurse manager and surgeon would get benefited by implementing hand hygiene because there would be less hospital readmissions due to infections and their work load would be reduced. There would be improvement in the quality of care of patients by these stakeholders. Probability of infection to these stakeholders would be reduced. These stakeholders would get benefited by implementing hand hygiene because they might be praised by the management of the hospital. Education about the hand hygiene should be provided to the preoperative nurse because due to less experience they might be less knowledgeable about hand hygiene. Nurse manager should be given responsibility of providing education and training to all the nurses in the hospital to implement hand hygiene practice. Hence, it would be mandatory for nurse manger to involve in the decision making. Surgeons would be provided with all the resources for implementation of hand hygiene practice (Srigley et al., 2016).  

F2 : Phenomenon known as the Hawthorne effect can be the potential barrier for implementation of hand hygiene. In this phenomenon, healthcare workers might act or showing  as they are following hand hygiene, however in practice, they are not following. It is evident from the research that knowledge and compliance in the nurse can be improved by providing education about the hand hygiene. However, there would be less chances of retention of trained nurses for the longer duration in the healthcare facility. This might be due to more workload. Hence, there would be more turnover of nurses in the surgery unit. Newly recruited nurses need to be trained again and there would be delay in the implementation of the hand hygiene policy in the hospital.  

Hawthorne effect can be prevented by continuous monitoring of the healthcare professionals. More turnover of nurses in the surgery department can reduced by offering these nurses with extra compensation and rewards for maintaining higher level of hand hygiene compliance.

Number of hand washings can be used as indicator to measure outcome of hand hygiene compliance. Number of hand washings can be measured quantitatively. Number of hand washings per day per person and number of healthcare workers washing hands can be measured to understand hand hygiene compliance. Washing of hands should be used to reduce contamination of healthcare workers with blood and other body fluids. It is also used to reduce risk of microorganisms dissemination to the surroundings. It can also be used to reduce dissemination of microorganisms from healthcare workers to patient and vice versa. Hands should be used during all the medical and surgical related activities (Srigley et al., 2016).

References:

Al Kadi A, Salati SA. Hand Hygiene Practices among

Medical Students. Interdisciplinary Perspectives on

Infectious Diseases 2012;16:1-6

Al Kadi A, Salati SA. Hand Hygiene Practices among

Medical Students. Interdisciplinary Perspectives on

Infectious Diseases 2012;16:1-6

Al Kadi A, Salati SA. Hand Hygiene Practices among

Medical Students. Interdisciplinary Perspectives on

Infectious Diseases 2012;16:1-6

O’Donoghue, M., Suk-Hing, Ng., Suen, L.K.P., and Boost, M. (2016). A quasi-experimental study to determine the effects of a multifaceted educational intervention on hand hygiene compliance in a radiography unit. Antimicrobial Resistance and Infection Control, 5, 36. DOI 10.1186/s13756-016-0133-4.

Goldberg, J. L. (2017). Guideline Implementation: Hand Hygiene. AORN Journal, 105(2), 203-212. doi:10.1016/j.aorn.2016.12.010

Shen, Li., Xiaoqing, W., Junming, A., Jialu, A., Ning, Z., Lu, S., & ... Xiaorong, L. (2017). Implementation of WHO multimodal strategy for improvement of hand hygiene: a quasi-experimental study in a Traditional Chinese Medicine hospital in Xi'an, China. Antimicrobial Resistance & Infection Control, 61. doi:10.1186/s13756-017-0254-4.

Santosaningsih, D., Erikawati, D., Santoso, S., Noorhamdan, N., et al., (2017). Intervening with healthcare workers’ hand hygiene compliance, knowledge, and perception in a limited-resource hospital in Indonesia: a randomized controlled trial study. Antimicrobial Resistance and Infection Control, 6, 23. DOI 10.1186/s13756-017-0179-y.

Srigle,  J.A., Furness, C.D., and Gardam, M. (2016). Interventions to improve patient hand hygiene: a systematic review. Journal of Hospital Infection, 94(1), 23-9.

Winship, S., and McClunie-Trust, P. (2016). Factors Influencing Hand Hygiene Compliance Among Nurses: An Integrative Review. Kai Tiaki Nursing Research, 7(1), 19-26.

Whitcomb, K. k. (2014). Using a Multidimensional Approach to Improve Quality Related to Students’ Hand Hygiene Practice. Nurse Educator, 39(6), 269-273.