Running head: HAND HYGIENE COMPLIANCE AND INFECTION 1 of 20
The Relationship between Hand Hygiene Compliance and Nosocomial Infections
David F. Bravo, Jennifer A. Earls and Alicia A. Johnson
N201: Introduction to Professional Nursing and Evidence Based Practice
Faculty: Deborah Lekan, MSN, RN
Evidence-Based Nursing Practice Synthesis Paper
Duke University School of Nursing, ABSN Program
26 April 2011
TABLE OF CONTENTS
Part I: The Clinical Question and PICO Worksheet, page 3
Part II: Research Article Summaries (3), page 5
Part III: Synthesis Paper, page 16
Part IV: Printout of Literature Search Strategy, page 20
N201 Introduction to Professional Nursing and Evidence-Based Practice
Class Session #3, April 3, 2011 (revised)
Part I. The Clinical Question and PICO Worksheet
1. Please describe the clinical scenario that generated your initial question about nursing practice and/or patient outcomes. *Consider a clinical scenario that you have observed in your clinical rotation, that concerns conflicting information in your readings, skills lab, and/or clinical rotation, or that addresses a nursing care issue for one of your patients.
Hand hygiene is stressed heavily as a standard care of practice at the very beginning of nursing school. As we are experiencing clinical for the first time we are highly aware of hand hygiene practices among our colleagues, both good and bad practices. Even though health care workers know that hand hygiene is important we’ve seen a lack of compliance in various clinical settings. We are curious to know if low compliance affects nosocomial infection rates.
2. Now, explore the question:
What is the problem, as you see it?
Risk of nosocomial infections due to hand hygiene compliance.
Why do you think this is important?
It is important to ensure healing of the patient by reducing infection and disease process complications. It also keeps costs down.
When does the problem occur?
The problem occurs during nurse/patient interactions that can include physical assessment, care giving, and implementation of nursing interventions.
Who is affected?
Patients receiving care in a hospital.
What Background Information do you need to learn before you can formulate the clinical question?
Statistical analysis of nosocomial infection rates. Hand hygiene adherence rates, qualitative studies on hand hygiene adherence and risk factors for low compliance.
3. Now, please write your EBNP question in your own words.
Can nurses reduce nosocomial infection through hand hygiene compliance and how important is hand hygiene at reducing nosocomial infections?
4. Take the next step and focus the question on key elements of the question you are most concerned about and write your clinical question using the PICO format, below.
This PICO format is designed for an intervention question. As you may recall from your readings, clinical questions may also focus on etiology, diagnosis, harm ….
For this assignment, please use an intervention question.
P / Patient or Problem / Risk of nosocomial infection.I / Intervention / Hand hygiene
C / Comparison / Actual compliance to hand hygiene versus optimal compliance standard precautions
O / Outcome / What do the studies show in regards to reducing nosocomial infections and hand hygiene? There is evidence that hand hygiene methods work but compliance must occur.
Part II. Research Article Summaries
Article #1: Picheansathian, W. (2004). A Systemic Review on the Effectiveness of Alcohol-based Solutions for Hand Hygiene. International Journal of Nursing Practice, 10, 3-9. (Systematic review combined Meta-Analysis Evidence Level: I).
Purpose: This is a systematic review article combined with meta-analysis. The purpose of the article is to determine if alcohol-based solutions are an effective form of hand hygiene, and how does it help reduce the transmission of nosocomial infections.
Background: Hand-washing has been regarded as the hallmark against the fight against nosocomial infections for many years now. This is because health care workers (HCWs) are susceptible carriers of microorganisms, virus and fungi. The risk for transmitting infections from patient to patient increases if no hand hygiene is performed. Interestingly hand hygiene does not stop the spread of infections but it does reduce it. Compliancy among HCWs, therefore, plays a role in helping to minimize the spread of infections. According to Picheansathian, studies regarding hand hygiene compliancy have not typically exceed 50% (3). The are two major risk factors associated with low compliancy on behalf of HCWs; the time required to perform hand hygiene and the aggravation of skin irritation after having performed hand hygiene. New forms of hand hygiene, as a result, are now being evaluated and studied to determine if it can help reduce the spread of nosocomial infections, which would be a great benefit to patients recovering in the hospital. An example of an alternative to hand-washing is the use of alcohol-based solutions Picheansathian, 3.)
Method: The study design was based on a systematic review with the incorporation of meta-analysis. First, the researchers performed a literature review using search engines, such as CINAHL, DARE and Medline. Terms used in their search were: alcohol, alcohol-based, hand washing, hand hygiene and compliance. Articles both published and un-published were used dating from 1992-2002. Unpublished articles were pulled from Dissertation Abstracts International. Second, articles were grouped according to their relevancy and were then assessed and reviewed by two reviewers. The reviewers used the Cochrane Collaboration and Center for Reviews and Dissemination as a guide to either include or exclude the research articles. The goal of this was to find articles that focused on the efficacy of alcohol-based solutions, compliance rates for HCWs using alcohol-based solutions, skin problems associated with the use of alcohol-based solutions and time required to perform hand hygiene. Any article that consisted of opinions, general literature reviews and any article that lacked explicit details were omitted (Picheansathian, 4).
Meta-analysis was used to help pool the articles according to their relevancy. Specific software and chi-square testing was undergone to better determine how related the articles were to the study. If the research articles found were unable to be grouped, the researchers chose to review them in a narrative form (Picheansathian, 4).
Results: Alcohol-based solutions were found to be an effective form of hand hygiene. Only when hands were visibly soiled did alcohol-based solutions prove not to be a good alternative to hand washing. The study undergone demonstrated that using ethyl alcohol-based solutions dramatically reduced the presence of MRSA on the hand of HCWs versus hand washing with anti-septic soap, by about 80% (Picheansathian, 6-7.) As was noted earlier, in order to help reduce the spread of nosocomial infections compliance on behalf of the health care teams is needed. By using alcohol-based solutions, HCWs were more willing to perform hand hygiene. Factors that increased the performance of hand hygiene compliance centered on less time required to perform hand hygiene, almost no skin irriations present after having used the alcohol-based solutions, and the direct access to the alcohol-based solution, often at the bed side. (Picheansathian, 6-7.)
Conclusion and Nursing Intervention: Results of the analysis showed that alcohol-based solutions are a good and adequate form of hand hygiene. Alcohol-based solutions were found to be less damaging to the skin which helped minimize skin irritations. It also demonstrated a decrease presence of microorganisms, especially when compared to hand-washing with antiseptic soap. Less time required to actually perform hand hygiene and there direct access increased HCW compliancy. Compliancy on behalf of the HCW team is needed in order to help reduce the spread of infections. In regards to our PICO question, the research article demonstrates that by performing hand hygiene via alcohol-based solutions, compliancy rates increase while spread of infection rates decrease.
Article #2: Bearman, Gonzalo M. L., Marra, Alexandre R., Sessler, Curtis N., Smith, Wally R., Rosata, Adriana, Laplante, Justin K., Wenzel, Richard P., Edmond, Michael B., (2007). A Controlled Trial of Universal Gloving Versus Contact Precautions for Preventing the Transmission of Multidrug-resistant organisms. American Journal for Infection Control, 35, 10, 650-655. (Case-control or cohort study, Evidence level IV).
Purpose: This controlled trial study was conducted to determine the efficacy of universal gloving and contact precautions for the control of multidrug-resistant organisms (MDRO) in an intensive care unit. It also attempted to measure compliance with universal gloving and contact precautions among health care workers and their attitudes toward both practices.
Background: The study is timely due to several factors. The emergence of MDROs led to the evolution of contact isolation with barrier precautions, (Bearman et al., 653). Contact precautions as detailed by the CDC are universal guidelines that when adopted are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient’s environment, (CDC, Isolation Precautions, 69-70). These precautions “apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission,” (CDC, Isolation precautions, 70). A single patient room is necessary to control transmission most effectively. If this arrangement is not available, health care personnel should ensure no less than 3 feet of distance (droplet precautionary distance) between patients in a multi-patient room. Healthcare personnel caring for these patients will don personal protective equipment prior to room entry and discard it before leaving. The door to the patient room will remain shut for the duration of contact precaution isolation.
Method: This study was conducted in a medical intensive care unit. It involved 2 phases of 3 months each. During both phases hand trained observers observed hygiene and infection control compliance. Each patient was cultured every 4 days for the colonization of VRE (perirectal culture) and MRSA (nasal culture). Patient statistics were collected for length of stay, occupancy rate, nurse/patient ratio, antibiotic usage in defined daily doses, and invasive device utilization ratios were calculated for the duration of the study, (Bearman et al., 2007, 650). The study followed 1090 patient-days, 1220 infection control compliance observations and 192 patients screened for VRE and 228 screened for MRSA in phase I. The second phase included 1377 patient-days, 1102 infection control compliance observations, and 257 patients screened for VRE and 301 screened for MRSA.
Finally, an anonymous questionnaire was given to ICU nurses and attending physicians encouraging them to self-assess their infection control compliance and how they viewed the acceptability of universal gloving versus contact precautions.
Statistical analysis was done using SPSS software. Comparisons between study periods were performed using Fisher exact test, X2 statistic test and t test for statistical variances. All tests used in this study were 2-sided with a significance level set at 05.
Results: The study found that hand hygiene was significantly higher in phase I than in phase II (18.7% vs. 11.4%) (Bearman et al., 651). According to Bearman, no differences were found in length of stay; mean occupancy rate; nurse to patient ratio; or the utilization of urinary catheters, central venous catheters, and mechanical ventilation between the utilization of contact precautions phase I and universal precautions of phase II.
Bearman et al. (2007, 652) reported nosocomial infection rates increased in phase II of the study, 3 were bloodstream infections (2 MRSA and 1 VRE) and 1 VRE urinary tract infection. No MRSA or VRE nosocomial infections were identified during phase I.
For the questionnaire, 65% of eligible health care workers responded (34 of 52). Of those respondents 30 were nurses and 4 were attending physicians. Ninety-seven percent thought their personal compliance with infection control measures and hand hygiene was good. Surprisingly 48% percent reported that they visited patient rooms less frequently when that patient was in contact isolation. This most likely led to 53% responding that they thought overall better patient care is delivered when no patients are placed in contact precautions.
Perceptions about pathogen transmission might play a role here. According to the questionnaire the health care workers found universal gloving acceptable and believed that it was associated with a decreased risk of cross transmission of pathogens, according to Bearman et al. (2007, 653). These workers also believed that overall better care was delivered with just universal gloving and no with contact precautions.
Conclusion and Nursing Interventions: Although the sample size was small and certainly a limitation in this study it is useful in illustrating that despite precautions nosocomial infections occur. Infection rates rose when patients were taken off of contact precautions. Surprisingly nurses did not interact with patients as much when those patients were on contact precautions. Therefore nosocomial pathogens were transmitted even when nurses spent less time with the patients.
It was determined that the nurses in this study preferred gloving only, due to the beliefs that it decreased risk of transmission and that better care was delivered when universal gloving was the norm, (Bearman et al., 652-653). Nurses generally believed that hand hygiene was sufficient to prevent and decrease the risk of transmission of pathogens in the hospital setting. Further it was found that health care workers believe universal gloving was associated with decreased risk of the cross contamination of nosocomial organisms and that better care was delivered under these precautions.
The subjective questionnaire was especially pertinent to our PICO question. We are attempting to determine how compliance affects pathogen transmission in the hospital. If caregivers do not utilize hand hygiene consistently their lack of compliance may affect nosocomial transmission rates. Therefore compliance to hand hygiene practices offers the best practice to reduce nosocomial transmissions within the hospital.
Article #3: Barrett, R., Randle, J. (2008) Hand hygiene practices: nursing students’ perceptions. Journal of Clinical Nursing, 17, 1851-1857. doi: 10.1111/j.1365-2702.2007.02215.x
Purpose: This qualitative study focuses on the factors that influence the choice of nursing students to comply with hand hygiene standards of care.
Background: Picheansathan (2004) found that the use of alcohol-based solutions for hand hygiene, when practiced, would be an effective tool against the spread of nosocomial infections. Furthermore, there has been evidence that health care workers do not consistently utilize hand hygiene methods in health-care settings, with some evidence suggesting that compliance rates were 50% or lower (Picheansathan, 2004, p. 3). With the evidence that hand hygiene, when done in a timely and correct manner, can prevent microorganism spread and the statistic that healthcare workers do not consistently adhere to hand hygiene policies, it is clear that there is a disjunct between knowledge and praxis. It is this mismatch that can have potentially dire consequences for the focal consumer of nursing services: the patient.