Evidence based practice paper: Hand Hygiene in Healthcare setting
Order Instructions:
Describe a Clinical Problem that you see or have seen in practice. You will then revise or develop a policy, protocol, algorithm, or standardized guideline to be used in your practice site that is based on current research evidence. You are proposing the implementation of an intervention that is supported by research; thus you are proposing an evidence-based practice (EBP) project. You are not proposing a
study to be conducted in your agency.
Your final paper should be no more than 10 pages but your protocol, policy, or algorithm, and references for your project can be extra pages. This assignment is worth 100 points
Identify an area of interest: Is there a better way of doing something? Would another intervention based on research be more effective and improve patient outcomes? Is a policy, protocol, or algorithm in your agency out of date and in need of revision based on current research?
2. Provide some information (incidence of problem, morbidity and mortality rates, cost, etc.) from the healthcare literature and your agency that supports the fact that this is a patient care problem.
3. Review recent research and practice literature and select a specific intervention that might
address this patient care issue. The research-based intervention may be implemented in the form of a policy, protocol, algorithm, or standardized guideline that you could use to change patient care.
4. Identify what evidence-based intervention exists to improve current care in terms of patient, provider, or healthcare agency outcomes? Try to identify something for which you really
want an answer. You might get ideas from your unit nursing leader, other nurses, or patients
and families. Search current research journals online for interventions that have been studied.
5. Review a variety of evidence-based practice (EBP) Websites such as:
- National Guideline Clearinghouse (http://www.guideline.gov)
- Center for Disease Control (http://www.cdc.gov/Other/policies.html)
Professional Organization Websites Evidence-Based Guidelines
See Chapter 19 in Grove, Burns, and Gray (2013) textbook for more details on conducting EBP Projects and EBP websites.
6. Summarize what is known and not known about the problem area selected.
7. Revise or develop a policy, protocol, algorithm, or standardized guideline to be used in your practice site.
8. Provide a copy of the policy, protocol, algorithm, or standardized guideline with its references.
9. The steps of the protocol, policy, algorithm, or standardized guideline must be documented with current studies.
10. If a previous agency protocol or policy is revised, specify the changes made in the document.
11. Provide a reference list for your paper.
12. The references should include 7-10 quality research sources that support the intervention you have selected to implement in your practice site.
Grading Rubric
Introduction
Rubric
(0 – 10 Points)
Identifies problem in practice and the intervention to be used to address problem. Identifies the audience who will use the protocol, algorithm, or policy revised or developed.
Documents introduction.
Review of sources: What is known
(0 – 30 Points)
Summarizes or synthesizes current research knowledge that identifies what is known about the selected intervention.
Summary must be documented with studies from published sources.
Summary provides the knowledge base or research evidence for making a change in practice.
Review of sources: What is not known
(0 – 15 Points)
Summarizes or synthesizes what is not known in the area of the selected intervention.
Summary must be documented.
Section identifies the areas for further research.
Protocol, Algorithm, Policy, or Standardized
Guideline for Evidence-Based Project
(0 – 20 Points)
Provide a copy of the documented protocol, algorithm, policy, or standardized guideline. The steps of the protocol, algorithm, or policy are documented with current research sources.
Discuss your development of your protocol, algorithm, policy, or standardized guideline. If revised from previous agency protocol, identify the changes made.
(0 – 10 Points)
Indicate whether protocol or algorithm was developed; revised from an agency document; or obtained from a publication or website.
If based on existing document, include a copy of this document.
Briefly identifies any revisions you might have made to the existing document.
Format and Writing style is clear, complete, and concise. No grammar, sentence structure, or spelling errors. References APA (2010) Format. Limit the paper to 10 pages
(0 – 15 Points) The references need to include 7-10 published research sources. All sections of the paper must be documented with research sources. Include headings based on the paper guidelines.
Total Points Possible: 100
SAMPLE ANSWER
Evidence based practice paper: Hand Hygiene in Healthcare setting
Hand hygiene (HH) is known to prevent cross-infection in health care organizations, but there is poor adherence of health care workers to hand hygiene guidelines. Timely, easy access to both skin protection and hand hygiene is essential for satisfactory hand hygiene behavior. The use of alcohol-based hand rubs is necessary given that they are less irritating, they act faster, and require less time than traditional hand washing, and they also contribute to sustained improvement in compliance related to reduced rates of infection (Pittet, 2011). It is disquieting that the hospitalization of a patient may result in Hospital Acquired Infection (HAI), also known as nosocomial infection, and that poor hand hygiene is considered as a contributory factor. This paper provides an exhaustive description of hand hygiene; a Clinical Problem that I have actually seen in practice. Moreover, a standardized guideline is developed in this paper that would be used in my practice site and this standardized guideline is based on current literature evidence. In essence, I am proposing the implementation of an intervention that is supported by research; hence I am proposing an evidence-based practice (EBP) project.
The Clinical Problem of Hand Hygiene in Healthcare setting
Hand hygiene (HH) is the most effective and simplest measure for the prevention of nosocomial infections. In spite of advances in infection control as well as hospital epidemiology, the adherence of healthcare workers (HCWs) to the recommended HH practices is unacceptably low and patients remain susceptible to unintentional harm in health care settings (Maxfield & Dull, 2011). It is of note that the average adherence to HH recommendations varies amongst professional categories of HCWs, between hospital wards, according to working conditions, and according to the definitions utilized in various studies. In most instances, compliance to HH practices by HCWs is estimated as less than 50% (Boyce, 2014). In the United States, poor adherence has led to high mortality and morbidity considering that there are between 1.7 million and 2 million persons who get Hospital Acquired Infections every year, and 88,000 to 99,000 deaths are attributed to Hospital Acquired Infections every year (Al-Busaidi, 2013). Moreover, Hospital Acquired Infection affects almost 10 percent of hospitalized patients and it presents great challenges in hospitals. As a result, yearly medical expenditures have risen to roughly $4.5 billion in the United States (Al-Busaidi, 2013).
The practice of Hand Hygiene amongst health care workers is regarded as the single most clinical and cost effective measure for preventing nosocomial infection, a view that is recognized all over the world (Canham, 2011). The World Health Organization strongly stresses the vital need for HH during health care delivery in order to avoid possible infection as well as the consequent health problems; hence, the WHO’s Clean Care is Safe Care initiative launched in the year 2005. It is of note that this initiative provides new guidelines on HH training, observation, as well as performance reporting in health care settings (Kukanich et al., 2013).
The hands of nurses come in close contact with patients and they are usually contaminated through patient care, for instance while touching surfaces, materials or devices that are contaminated, or auscultation and palpation. As such, HH is seen as a cheap, vital, and most effective way to prevent cross infection (Cambell, 2010). This method is essentially aimed at saving lives and provides a safe treatment atmosphere for every health care worker and patient, irrespective of the setting. Bischoff (2000) stated that HH has to be considered after contact with high risk, infectious patients, and with contaminated materials or devices, as well as prior to invasive procedures. In essence, HH has to be advocated before a HCW begins work, at the end of her work, and after visiting the toilet/rest room. Even when nursing staffs spend a longer duration of time on HH, there hand hygiene technique is usually poor relative to other health care workers in terms of leaving large areas of the hand unwashed properly, including between fingers, nail beds, thumbs, as well as wrists (Maxfield & Dull, 2011).
Hand hygiene, in essence, is not just the responsibility of the nurses. Hand hygiene is a shared responsibility between patients, main leaders of the hospital, hospital administration, and other stakeholders. Boyce (2014) observed that patient involvement generally increases adherence to HH practice by 50 percent if, for instance, a straightforward question is asked of the HCW, like: have you washed your hands? Most patients think that asking health care workers to clean their hands before health care delivery is a disloyalty of trust. Moreover, some of them actually believe that they could be labeled as a troublemaker; hence, they choose not to ask. Patients typically feel reassured if they observe health care workers practice effective hand hygiene within the health care setting (Al-Busaidi, 2013).
Barriers to Hand Hygiene Practice in Health Care Settings
A lot of factors lie behind poor HH compliance amongst health care workers. Nursing staff members are ethically and professionally responsible for their actions. Nonetheless, some nursing staffs display low compliance since they perceive hand hygiene as not their problem; that it is instead something to do with the staffs of infection control. Moreover, nursing staffs usually fail to practice HH since they are very busy and they think that hand hygiene will take up their precious time (Canham, 2011). Additionally, they usually believe that gloves can be utilized as an alternative to HH, and this is a major misconception that contributes to poor adherence. Nurses often have the tendency of removing gloves without washing their hands. They also tend to use the gloves in delivering intended care to many patients. Even when nurses remove their gloves, just 20 percent of them actually wash their hands (Pittet, 2011).
Furthermore, nursing staff member usually avoid HH practice because they have the fear that skin problems for instance dermatitis might develop, particularly when alcohol hand-rubs are used in the hand hygiene practice – another misconception. They think that skin irritation occurs as a result of frequent HH practice (Whitby, 2006). Moreover, limited time, lack of organizational pledge to proper HH practice, increased workloads, lack of motivation, lack of role models amongst seniors or colleagues, under-staffing, and disagreement with protocols and guidelines all contribute to poor adherence to hand hygiene and infection control measures in health care settings. Maxfield and Dull (2011) observed that the dearth of hand hygiene facilities and products, for instance hand paper towels, non-antiseptic and antiseptic soaps, sinks, alcohol hand-rubs, and running water can also contribute to bad hand hygiene practice.
Another noteworthy barrier is a lack of awareness and scientific knowledge with regard to hand hygiene. Bischoff (2000) stated that the lack of appropriate infection control in training programs, where students watch their colleagues with patients, might actually result in bad HH practice. Otto and French (2009) in their study learned that the cultures and attitudes of nurses at work have a significant influence in clinical development of students, and for the students to be accepted in that culture, they have a tendency to follow their mentors and other health care workers. A case in point is that for a student to be perceived as being an effective team member, she/he tends to perform hand hygiene poorly and improperly, since this student wants to appear as busy as her mentors and believes that she does not have enough time to wash her hands (Al-Busaidi, 2013).
The behavior and attitudes of HCWs toward HH practice is an intricate issue that involves the perception of its efficacy, existing barriers, as well as beliefs and values of staffs. To attain high rates of compliance with hand hygiene practice, Otto and French (2009) suggested that those who default have to be disciplined as if they have breached hospital policy, and this should start with personal counseling to verbal warning, and at last to a written warning placed in the files of the defaulters.
Effective Hand Hygiene
Effective HH basically involves removing the visible soiling as well as the reduction of microbial colonization of the skin. The hands of HCWs could be contaminated by 2 sorts of pathogens: (i) resident – colonizing or normal – microorganisms, and (ii) transient – contaminating – microorganisms. Resident flora microorganisms are known to colonize the deeper layers of the skin, and unlike transient flora, they are not easy to remove mechanically; that is, through washing hands (Smith & Lokhorst, 2009). Luckily though, resident flora is less aggressive compared to transient flora, and is less likely to lead to serious infection. Examples of resident flora include negative staphylococci and Corynebacteria. It is of note that these bacteria are inclined to grow within the hair follicles and remain moderately dormant over time (Smith & Lokhorst, 2009).
Conversely, transient flora colonize the superficial layers of the skin for a short period of time. The nurses’ hands are frequently contaminated with transient flora through direct contact during every day patient care activities, equipment or environments. Nonetheless, transient flora can be removed easily through the use of mechanical methods, for instance friction in hand washing. Examples of transient flora include Candida species and Staphylococcus aurous. Transient flora are able to induce nosocomial infection amongst health care workers and patients (Al-Busaidi, 2013). Considering this information as regards resident and transient bacteria, effective hand hygiene practice either with the use of alcohol-based hand-rub or hand washing using antimicrobial soap, is clearly the way to reduce the risk of cross infection.
Research-Based Intervention in the form of a Standardized Guideline
Promotion of HH practices in health care settings is a significant challenge for infection control experts. Lectures and workshops, distribution of information flyers, performance feedback on adherence rates, and in-service education have all been linked to transient improvement. There is really not a single intervention that has repeatedly improved adherence to HH practices (Smith & Lokhorst, 2009). Given that nursing staff members are present twenty-four hours a day, seven days a week within the health care setting, it is of major importance to stick to HH standardized guideline and maintain patient safety. The following guideline should be followed by health care facilities.
- Encourage effective hand washing
Effective hand washing, according to Pittet (2011), is the application of antimicrobial/antiseptic or non-antimicrobial/plain soap onto wet hands. The individual should then rub together both hands vigorously to form lather, and should cover base of the fingers, tops of the hands, all the surface of the palms, fingernails, wrists, thumbs, back of the fingers, and between fingers for a 60 seconds. The health care worker should ensure that his/her fingernails are short. Boyce (2014) reported that artificial fingernails are possible traps for bacteria and thus have to be avoided. Although chipped nail polish has the capacity of harboring bacteria, new nail polish on natural nails in fact does not worsen the microbial load. It is of note that wearing jewellery, for instance hand watches or rings, may actually bring about bacterial colonization on the skin beneath them. After the HCW has soaped and rubbed, she should rinse her hands thoroughly to remove all the lather on the hands. Hot water should not be used in rinsing given that it may lead to dryness of the skin (Al-Busaidi, 2013).
Hand drying is also of major importance in the prevention of cross infection in the health care setting since microorganisms are known to thrive in damp environments. Hand drying should be done before the HCW wears her gloves, as trapped moisture in the gloves may lead to irritation of the skin and increase the harboring of microorganisms (Whitby, 2006). Paper towels are very efficient in drying hands and the friction created whenever they are used actually improves the removal of microorganisms from the skin. The HCW must not touch the tap again after she has just washed her hands; she should use a paper towel in turning the water off. Even though hand driers are just as good as hand towels, paper disposable hand towels are generally more effective and are quicker. In essence, the friction that is produced through hand rubbing with soap vigorously and then hand drying using paper towels actually removes all the dirt as well as any loosely adherent flora; that is, small portion of resident flora and nearly all transient flora from hands (Smith & Lokhorst, 2009).
- Encourage the use of alcohol hand-rub
There is sufficient evidence to recommend the alcohol hand-rub owing to its cost effectiveness and clinical benefits. Pittet (2011) pointed out that the likelihood of hand washing to wash away the skin’s fats and oils that are vital for healthy skin is less with the usage of hand-rub. Simply put, alcohol hand-rub will redistribute the lipids in the layers of the skin. In addition, alcohol hand-rub can dispense with paper towels. In his study, Cambell (2010) found that alcohol hand-rub actually consists of several emollients that are better tolerated by health care workers compared to hand washing. Cambell (2010) also found that quite a few factors including consistency, odor, and color of alcohol hand-rub products can influence health care workers’ acceptance of this product. Alcohol hand-rub dispensers could be positioned readily and accessed easily: at the bedside of patients, outside and inside of the rooms of patients, in waiting areas, next to computers, and even inside the nursing stations (Kukanich et el., 2013).
Effective usage of alcohol hand-rub basically implies that health care workers have to strictly comply with the manufacturer’s instructions, particularly with regard to the quantity used as well as the time required to completely fade away from the hands. In essence, the availability of alcohol hand-rub products at the point of care has to be supplemented by the availability of gloves in suitable sizes. From his study, Bischoff (2000) observed that hospitals that made clean gloves and alcohol-based hand rub readily available to HCWs saw improved compliance with hand hygiene.
- Clarify misconceptions about the usage of gloves
To improve healthcare workers compliance with HH practice, it is of major importance to take into account the hindering factors and then turn them into factors that enhance compliance. The misconceptions of nurses regarding the use of gloves and skin complications should be clarified so as to attain a better compliance with HH practice. In essence, failure to remove gloves following contact with patient or between clean and dirty body site care for the same patient actually amounts to poor adherence to hand hygiene recommendations (Boyce, 2014). The nursing staffs need to be informed that it is ineffective to wash and reuse gloves between patient contact. Disinfection or hand washing has to be strongly encouraged following removal of gloves (Canham, 2011).
- Provide Training and Education on Hand Hygiene
Proper education as well as follow-up training is key to identify situations in which HH is reasonable. Important educational materials that the hospital should use include the following: computer-assisted, interactive learning that is made available to the clinicians through the hospital’s intranet; and PowerPoint presentations and videotapes that illustrate the significance of good HH techniques in hospitals and other health care facilities. Hospitals should conduct educational programmes for employees that comprise instructions for appropriate method when using an alcohol-based hand-rub, or washing hands using water and soap. The hospital should make sure that health care workers comprehend the underlying principle for gloves and hand hygiene and can follow the best practices and enhance patient outcomes (Pittet, 2011).
- Place promotional materials in noticeable areas
In essence, hand hygiene promotion posters should be placed in locations that are highly visible throughout the healthcare facility and a multi-modal campaign for improving performance should be initiated. Whitby (2006) pointed out that promotional material, for instance posters, could be placed in noticeable areas of the health care facility and they will be aimed at reminding patients, health care worker, as well as visitors about the significance of HH practice. In addition, the hospital can also place videos on the wards in order to show patients the importance of HH in the prevention of cross infection and to remind or ask health care workers to practice HH before health care delivery. In their study, Kukanich (2013) found that placing appropriate HH technique illustrations close to alcohol hand-rub dispensers or above sinks helped in improving compliance to hand hygiene. Moreover, Kukanich (2013) found that posters with pictures of renowned hospital physicians/personnel recommending hand hygiene also helped to improve compliance with hand hygiene in the health care facility. To motivate computer user to comply with hand hygiene practice, Smith and Lokhorst (2009) pointed out that messages on the subject of hand hygiene practice can be set on computer screensavers.
- Hand Hygiene products should be always available, and in right places
The ward or unit manager should ensure that hand hygiene products are at all times available, and are actually in the right places. Some of these places include offices, nursing station, as well as outside and inside of all patient rooms. Studies have revealed that compliance by HCWs was substantially greater when alcohol-based rub dispensers were placed adjacent to the bed of patients compared to when they was just a single dispenser for every 4 beds (Al Busaidi, 2013). Moreover, in critical care settings, studies have indicated that the availability of alcohol-based hand-rub at the point of care actually minimized the time constraint related to HH during patient care and it predicted better adherence to HH practice. Pittet (2011) in a study of hand hygiene amongst doctors, learned that easy access to an alcohol-based hand rub was in fact an independent predictor of improved compliance to HH practice.
- Recognize clinicians with good hand hygiene practice and create a culture of proper hand hygiene
It is of major importance for the health care organization to recognize nursing staff members with proper hand hygiene. This can be done, for instance, though announcement in the hospital’s newsletter. This will serve as a vital accolade that can actually encourage other nurses and health care workers to do likewise. The hospital should also create a culture that encourages staff members to remind each other as regards proper hand hygiene (Otto & French, 2009). In their study, Cambell (2010) found that when health care workers reminded each other and other health care workers to practice hand hygiene, there was a considerable increase in compliance to hand hygiene practice at the health care facility. All in all, the hospital should monitor compliance by HCWs with the recommended indications for HH, including real-time feedback to staff members.
Conclusion
In conclusion, the practice of Hand Hygiene amongst health care workers is regarded as the single most clinical and cost effective measure for preventing nosocomial infection. However, notwithstanding advances in infection control as well as hospital epidemiology, the compliance of clinicians with the recommended hand hygiene practices is unacceptably low and patients are very susceptible to inadvertent harm in health care settings. Hand hygiene is fundamentally aimed at saving lives and to provide a safe treatment atmosphere for every health care worker and patient, no matter the setting. In America, improper compliance with hand hygiene practices has led to high mortality and morbidity bearing in mind that there are more than 1.7 million persons who catch HAI every year, and over 90,000 deaths are attributed to HAI every year. Several factors actually contribute to poor hand hygiene compliance amongst clinicians. These include limited time, lack of organizational pledge to proper HH practice, increased workloads, lack of motivation, lack of role models, and under-staffing.
The proposed intervention as described in the guideline entails the following: making hand hygiene products always available and in the right places such as in nurse stations and at patient bedsides; and to recognize clinicians with effective hand hygiene practice and creating a culture of proper hand hygiene in the hospital. Moreover, the hospital should place promotional materials in noticeable areas, and provide education and training programs on the significance of proper and hand hygiene and how to actually practice effective hand hygiene.
References
Al-Busaidi, S. (2013). Healthcare Workers and Hand Hygiene Practice: A Literature Review. Diffusion, 6(1): 81-89
Bischoff, W. E. (2000). Handwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med. 160(7):1017-21
Boyce, J. M. (2014). Preventing Infections: It’s in Your Hands. Medscape Infectious Disease.
Cambell, R. (2010). Hand-washing compliance goes from 33% to 95% steering team of key players drives process, Healthcare Benchmarks and Quality Improvement 17:1, 5-6.
Canham, L. (2011). The first step in infection control is hand hygiene, The Dental Assistant, 42-46.
Kukanich, K. S., Kaur, R., Freeman, L. C., & Powell, D. A. (2013). Original Research: Evaluation of a Hand Hygiene Campaign in Outpatient Health Care Clinics. American Journal of Nursing, 113(3):36-42
Maxfield, D. & Dull, D. (2011). Influencing hand hygiene at spectrum health, Physician Executive Journal 37:3, 30-34.
Otto, M. & French, R. (2009). Hand hygiene compliance among healthcare staff and student nurses in a mental health setting, Mental Health Nursing 30, 702-704.
Pittet, D. (2011). Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach. Emerging Infection Disease Journal, 7(2): 32-8
Smith, J.M. & Lokhorst, D.B. (2009). Infection control: can nurses improve hand hygiene practice?, Journal of Undergraduate Nursing Scholarship 11:1, 1-6.
Whitby M. (2006). Why healthcare workers don’t wash their hands: a behavioral explanation Infect Control Hosp Epidemiol; 27(5):484-92.
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