Hygiene Protocol to Reduce Hospital Acquired Infections
Hygiene Protocol to Reduce Hospital Acquired Infections
Critique: The goal is a balanced constructive review including strengths and weaknesses as well as providing suggestions for how the study might be improved. Keep in mind that you are critiquing the article to determine if it can or should be used in your practice as a nurse.
Instructions: attached is the study selected to critique answering the following questions:
1. Research Problem
a) Is the problem identified clearly?
b) Is the problem significant, and do(es) the researcher(s) provide a good
argument for significance?
c) Is the problem relevant to nursing/health care?
2. Literature Review
a) Is it convincing that the author(s) reviewed a sufficient amount of
literature? Is the review comprised only of primary sources? Are
references current, or a combination of current and classic?
b) Is the review balanced, presenting literature that supports and that
differs from the researcher(s) position?
c) Is the review written critically, presenting both strengths and weaknesses of
previous work?
3. Theoretical Framework
a) Is a theoretical framework specified?
b) If so, does the framework “fit” the problem? Does it include all
relevant variables? Are the concepts (variables) clearly defined?
Are the results interpreted in reference to the theoretical framework?
c) If not, should there be one? Is it difficult to understand the
relationships among the variables in the study without a framework to
tie the pieces together? (Note: qualitative research, descriptive
studies, and physiologic studies typically will not specify a
theoretical framework.) Hygiene Protocol to Reduce Hospital Acquired Infections
4. Variables/Hypotheses
a) Are the variables in the study appropriate to the problem? Are they
relevant to nursing practice? Are the means to measure the
variables appropriate?
b) Are hypotheses stated? If so, what are they? Are they clear,
specific and testable?
c) If not, do(es) the researcher(s) provide sufficient information to
determine what the hypotheses were?
Patient Safety Issues U SE 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 EBR Evidence-Based Review on pp 225-226 ©2015 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2015898 216
Background Critically ill patients are at marked risk of hospitalacquired infections, which increase patients’ morbidity and mortality. Registered nurses are the main health care providers of physical care, including hygiene to reduce and prevent hospital-acquired infections, for hospitalized critically ill patients. Hygiene Protocol to Reduce Hospital Acquired Infections
Objective To investigate a new patient hand hygiene protocol designed to reduce hospital-acquired infection rates and improve nurses’ hand-washing compliance in an intensive care unit. Methods A preexperimental study design was used to compare 12-month rates of 2 common hospital-acquired infections, central catheter–associated bloodstream infection and catheterassociated urinary tract infection, and nurses’ hand-washing compliance measured before and during use of the protocol.
Results Reductions in 12-month infection rates were reported for both types of infections, but neither reduction was statistically significant. Mean 12-month nurse hand-washing compliance also improved, but not significantly. Conclusions A hand hygiene protocol for patients in the intensive care unit was associated with reductions in hospitalacquired infections and improvements in nurses’ hand-washing compliance. Prevention of such infections requires continuous quality improvement efforts to monitor lasting effectiveness as well as investigation of strategies to eliminate these infections. (American Journal of Critical Care. 2015;24:216-224) AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2015, Volume 24, No. 3 www.ajcconline.org A n estimated 2.5 million hospital-acquired infections (HAIs) occur annually in the United States.
These infections are associated with 90 000 preventable deaths of patients and financial costs in excess of $4.5 billion annually.1 Deaths due to HAIs are usually attributed to suboptimal practice by health care workers (HCWs), particularly poor hand hygiene.1,2 Global health care initiatives, nationwide hospital campaigns,1,2 and numerous creative quality-improvement strategies aim to improve HCWs’ hand-washing compliance and have led to individual hospital savings of up to $2.5 million annually.
1,2 In 2008, as a response to the American epidemic of HAIs, the Centers for Medicare and Medicaid Services created new rules denying hospital reimbursement for costs associated with conditions not present on admission.3 Central line–associated bloodstream infections (CLABSIs) are listed as 1 of the 10 conditions not eligible for reimbursement.4 Compared with other HAIs, CLABSIs are associated with the highest mortality among patients in intensive care units (ICUs).5 According to current publications, many hospitals have implemented quality-improvement strategies in the ICU to decrease estimates of CLABSI prevalence as high as 20% to 30%,6,7 the up to $40 000 cost associated with each CLABSI occurrence,8,9 and ultimately the mortality rates (some reported as high as 25%).
10 Improving HCWs’ hand-washing practices is an effective method to reduce the prevalence of HAIs,11,12 and such improvement is identified by the California Department of Public Health as the first intervention to prevent HAIs.13 Many creative strategies have been investigated to monitor and improve HCWs’ hand-washing compliance, including the use of chlorhexidine gluconate (CHG) disinfectant. Baths with CHG were recommended by the Centers for Disease Control and Prevention to reduce the occurrence of HAIs14 and have been used as the primary bathing method in many hospitals for ICU patients since 2009.5,15,16 Adoption of CHG baths has not been established in all ICUs. Hygiene Protocol to Reduce Hospital Acquired Infections
ICU patients experience many barriers to adequate hand hygiene for themselves, including immobility related to being connected to monitor cables and devices, lack of access to needed supplies, critical illness, confusion and delirium, and inconsistent About the Authors Cherie Fox is nurse manager of the cardiac intensive care unit, Teresa Wavra is a clinical nurse specialist, Diane Ash Drake is a nurse research scientist, Debbie Mulligan is an infection prevention manager, Yvonne Pacheco Bennett is a staff nurse, Carla Nelson is a infection control practitioner, Peggy Kirkwood is a cardiovascular nurse practitioner, Louise Jones is a staff nurse, and Mary Kay Bader is a neurological/critical care clinical nurse specialist at Mission Hospital, Mission Viejo, California. Corresponding author: Cherie Fox, RN, MSN, CCRN-CSC, Mission Hospital, 27700 Medical Center Road, Mission Viejo, CA 92691-6426 (e-mail: cherie.fox@stjoe.org). www.ajcconline.org hand hygiene practices by providers.
In a study17 conducted in a mixed medical surgical unit, researchers reported that patients unable to wash their hands had their hands washed by nurses only 14% of the time. Many factors and beliefs influence why HCWs do not wash their hands or a patient’s hands: attitude, lack of awareness of outcomes, social pressure, control, and prior life experiences.1 Intended Improvement: Patient Hand Hygiene Protocol The hospital in the present study (Mission Hospital) had not adopted the use of daily bathing with CHG because of concerns associated with the deactivation of skin care products used in the prevention and treatment of pressure ulcers.
13 This concern was not supported by published reports, but was a concern raised by our skin care team. Because CHG baths were not adopted, the ICU’s shared governance council decided to continue soap and water baths and evaluate the use of 2% CHG wipes applied to patients’ hands 3 times a day as a method of reducing HAIs. Hygiene Protocol to Reduce Hospital Acquired Infections
The intervention was identified as the “patient hand hygiene protocol (PHHP).” CHG was chosen because it provides continuous microbial killing for up to 6 hours by disrupting the bacterial cells and causing cytoplasmic leak and cell death.18 Hospital-acquired infections are associated with 90 000 preventable deaths of patients annually. Hygiene Protocol to Reduce Hospital Acquired Infections
AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2015, Volume 24, No. 3 217 Patient admitted to cardiac intensive care unit Intensive care unit nurse: review welcome packet flyer on hand hygiene with patient and patient’s family Nursing assessment Does patient have a contraindication to chlorhexidine? No Contraindications to chlorhexidine: 1. Hygiene Protocol to Reduce Hospital Acquired Infections
Allergy to chlorhexidine 2. Hygiene Protocol to Reduce Hospital Acquired Infections
Open wounds on hands 3. Other indications Yes Methods Proceed with intervention Clean patient’s hands with one 2% chlorhexidine wipe 3 times a day: 8 AM, 2 PM, and 8 PM Document in medical record: yes, no (why no) The study was approved by the hospital’s institutional review board. Informed consent was waived because the study met the criteria for a quality improvement program. Does patient show signs of drying, cracking, or Yes irritation? No Continue with the intervention as planned and assess hands with each application. Hygiene Protocol to Reduce Hospital Acquired Infections
Study team will provide a more thorough assessment twice a week. Stop Continue with the intervention as planned and apply lotion 3 times a day and as needed Yes No Does patient ontinue to have dry, cracked, or irritated hands that do not improve with lotion? Do not use chlorhexidine on patient Alternative intervention: Clean patient’s hands with Step 1 foam and dry cloths 3 times a day: 8 AM, 2 PM, and 8 PM Continue with the intervention as planned and apply lotion 3 times a day and as needed Figure 1 Hand hygiene protocol from the hand hygiene study. A 2% CHG cloth (500 mg of CHG per cloth) was used for ICU patients’ hand hygiene 3 times a day (Figure 1). Hygiene Protocol to Reduce Hospital Acquired Infections
A quality improvement strategy was proposed to (1) train every nurse to demonstrate the PHHP competently, (2) monitor nurses’ use of the PHHP, (3) monitor nurses’ hand washing before 218 they enter and leave ICU patients’ rooms, and (4) conduct a study to evaluate rates of HAIs (CLABSI and catheter-associated urinary tract infection [CAUTI]) and nurses’ hand-washing compliance rates before and after implementation of the PHHP. The purpose of this quality improvement study was to answer 2 research questions. 1. Is the PHHP associated with decreased CLABSI and CAUTI rates in the ICU? 2. Is the PHHP associated with increased handwashing compliance among ICU nurses? Setting The study was conducted in a 27-bed adult cardiovascular medical ICU at Mission Hospital in Mission Viejo, California, a 498-bed community hospital. Hygiene Protocol to Reduce Hospital Acquired Infections
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. Hygiene Protocol to Reduce Hospital Acquired Infections
Protocol Training A 10-week protocol phase-in period was scheduled by the study team for protocol training of ICU staff. All members of the nursing staff received verbal instructions from a study team member and were monitored for proper return demonstration of the protocol to improve consistency of their technique for hand hygiene. Hygiene Protocol to Reduce Hospital Acquired Infections
An electronic medical record “intervention” was created to trigger a timely reminder to perform the PHHP 3 times a day. The prompt in the electronic medical record also required nurses to document hand hygiene with a “yes” or “no” and to provide a comment response. Hygiene Protocol to Reduce Hospital Acquired Infections
If the nurse documented “no” (meaning the patient did not receive hand hygiene), the nurse was required to enter a comment explaining the rationale. Implementation and adherence were achieved through the 10-week training process, where study team members were present for each scheduled hand hygiene time (8 AM, 2 PM, and 8 PM). Hygiene Protocol to Reduce Hospital Acquired Infections
After the training period, auditing and observation were used to assess compliance. Resistance was met, as with any change, and was addressed on a 1-to-1 basis.
AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2015, Volume 24, No. 3 www.ajcconline.org Number of patients 350 300 250 20 150 100 50 0 11 11 ry 20 ua r eb F ch ar M 1 11 01 20 Ap 2 ril M ay 11 11 20 ne 20 ly Ju Ju 1 1 01 20 gu S Date Documentation audit ob ct O 1 01 2 er b t ep 1 01 2 er em Au 1 01 2 st 2 er b em v No 12 01 2 er 12 20 ry a b em c De ry nu Ja 20 ua br Fe Observational audit Figure 2 Nurses’ adherence with the patient hand hygiene protocol (documentation audit) and biweekly observational audit for compliance. Implementation The primary ICU nurse introduced the protocol to each patient and/or patient’s family, and a document explaining the protocol was added to each ICU patient’s admission packet. Hygiene Protocol to Reduce Hospital Acquired Infections
All patients admitted to the ICU were included in the study. Contraindications for CHG use included allergy to CHG, open wounds on hands, and/or other indications such as fissures or scales on hands. If CHG was contraindicated, a substitute nonrinse soap and wipes were used and a sign was posted outside the patient’s room indicating “no CHG.” Monitoring Protocol Adherence and Documentation of Skin Reactions Two documents were created and maintained throughout the study period to assess and report nurses’ adherence to the PHHP. Hygiene Protocol to Reduce Hospital Acquired Infections
1. Nurse documentation of protocol adherence: a daily report in the electronic medical record of the frequency of nurse documentation of yes, no, and provided comments to the PHHP. 2. Nurse adherence audit: a biweekly audit completed by a nurse on the study team observing frequency and timeliness of nurses’ completion of the PHHP. Report results were compared biweekly to measure nurses’ adherence to the protocol (Figure 2).Hygiene Protocol to Reduce Hospital Acquired Infections
Protocol adherence was defined as washing the patient’s hands at 8 AM, 2 PM, and 8 PM. A 1-hour grace period for the nurse to wash the patient’s hands was established. Nurses were prompted with a timesensitive reminder in the electronic medical record to document all 3 patient hand hygiene episodes, as well as assess the patient’s hands for cracking, fissures, scales, redness, and dryness during hand hygiene. Hygiene Protocol to Reduce Hospital Acquired Infections
The www.ajcconline.org Table 1 Criteria for assessment of skin reactions in a biweekly skin audit Erythema 1 2 3 4 Slight redness (spotty or diffuse) Moderate redness (uniform redness) Intense redness Fiery red (with edema) Scaling 1 Fine 2 Moderate 3 Severe Fissures 1 Fine cracks 2 Single or multiple cracks and/or broad fissures 3 Wide cracks with hemorrhage or exudate Stinging 0 No 1 Yes Itching 0 No 1 Yes Reprinted from Frosch and Kligman,20 with permission from Elsevier. Hygiene Protocol to Reduce Hospital Acquired Infections
repeated use of CHG had the potential to remove protective substances on the surface of the hands, making the hands more pliable with greater risk for cracks and fissures.19 Skin assessment criteria originally developed by Frosch and Kligman20 to study skin reactions to soaps were adapted for the study to evaluate skin reactions to CHG use (Table 1). Hygiene Protocol to Reduce Hospital Acquired Infections
If skin AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2015, Volume 24, No. 3 219 Table 2 Demographics of patients in the study Before protocol During protocol Days in intensive care unit, mean 3.69 3.46 Days in hospital, mean 7.35 6.96 Severity of illness, % of patients Minor Moderate Major Extreme 14 21 33 32 9 22 32 37 Age in years, No. of patients 17-35 36-55 56-75 76-90 ≥ 91 167 407 901 614 94 164 482 911 705 64 Population, No. (%) of patients Cardiac Medical Surgical n = 2183 773 (35) 1108 (51) 302 (14) n = 2326 900 (39) 1091 (47) 335 (14) Sex, No. (%) of patients Male Female 1249 (57) 934 (43) 1361 (59) 965 (41) 22.7 22.3 Characteristic Mean daily census reactions were observed, Aloe Vesta skin conditioner (lotion) was applied to the patient’s hands 3 times a day following the CHG protocol (Figure 1).
Study team nurses also completed an assessment of all patients’ hands twice a week. Reactions or irritations were documented in the electronic medical record, and the alternative hand hygiene protocol was used thereafter (Figure 1). Hygiene Protocol to Reduce Hospital Acquired Infections
Additionally the study’s principal investigator was alerted, who then notified the institutional review board in writing. Study Design A preexperimental (posttest only with a comparison group) study design was conducted. All study data were collected from a single ICU beginning in December 2009 and ending February 22, 2012. The investigation included 3 consecutive phases: (1) a comparison 12-month period before protocol implementation, (2) a 10-week protocol training period, and (3) a 12-month period during the protocol implementation. Hygiene Protocol to Reduce Hospital Acquired Infections
Patient-related variables including age, sex, hospital length of stay, severity of illness, and daily census were collected to compare variables that might contribute to differences in HAI rates (Table 2). Analysis Statistical analyses were conducted by using SPSS version 21. Rates of HAIs (both CAUTIs and CLABSIs) and nurses’ hand-washing compliance before 220 and during implementation of the PHHP were compared from two 12-month periods. Hygiene Protocol to Reduce Hospital Acquired Infections
A ² test was used to compare changes in HAI rates and also changes in nurses’ hand-washing compliance rates. Significance was defined as a P less than .05. Results In the year before protocol implementation, 2183 patients were admitted to the ICU compared with 2326 admitted during the protocol (Table 2). All patients admitted to the ICU were included in the study. However, 3 patients did not receive hand hygiene with CHG because of blisters, dry cracked skin, and a known CHG allergy. The mean daily census was 22.7 before the PHHP and 22.3 during the PHHP. More males than females were admitted to the ICU, comprising 57% of patients before and 59% of patients during the PHHP. Hygiene Protocol to Reduce Hospital Acquired Infections
HAI Rates CAUTIs were measured and reported by using the Centers for Disease Control and Prevention’s definition: incidence per 1000 indwelling urine catheter days. CAUTI results were summarized by comparing monthly means before and during implementation of the PHHP (Figure 3). The mean monthly CAUTI rate decreased from 9.1 to 5.6 per 1000 catheter days. The decrease in CAUTI rates was not statistically significant, 110 (N=12)=120, P=.24.
Device utilization days decreased from 5190 days to 4992 days; could the reduction in device days have contributed to the reduction in CAUTIs? Differences in device days during the 2 study periods were analyzed to evaluate their contribution to improved outcomes, but no significant difference was found between urinary catheter days before the PHH P (mean, 399.23; SD, 106.26) and during the PHHP (mean, 384; SD, 111.81), 132 (N=13)=143, P=.24. Hygiene Protocol to Reduce Hospital Acquired Infections
CLABSIs were measured and reported by using the Centers for Disease Control and Prevention’s definition: incidence per 1000 central catheter days. CLABSI results were summarized by comparing monthly means before and during the PHHP (Figure 3). The mean monthly CLABSI rate decreased from 1.1 to 0.50 per 1000 catheter days. Hygiene Protocol to Reduce Hospital Acquired Infections
The differences in CLABSI rates were not statistically significant 8 (N=12)=6.08, P=.64. During the study protocol, there were 0 CLABSIs for 9 months, which unfortunately ended with 1 CLABSI 2 weeks before the end of the study. Device utilization days decreased from 6447 days to 5620 days; could the reduction in device days have contributed to the reduced CLABSI rate? No significant difference was AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2015, Volume 24, No. 3 www.ajcconline.org No. of infections per 1000 catheter days 14.0 12.0 10.0 8.0 6.0 4.0 2.0 Rate of CAUTIs 20 ry r2 Fe ec br ua em be er D Training period 12 1 01 11 20 01 ug A O ct ob us t2 20 e Ju n Fe D Before protocol 1 11 1 pr il 2 A br ua em be ry r2 20 01 11 0 01 10 20 er ec ug A Fe O ct ob e us t2 20 01 10 0 Ju n A br ua ry pr il 2 20 01 10 9 00 r2 em be ec D 0 0.0 During protocol Rate of CLABSIs Figure 3 Rates of central catheter–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). Hygiene Protocol to Reduce Hospital Acquired Infections
Nurses washing hands, % 100 80 60 40 20 Training period Before entering patient’s room 12 20 01 Fe br u ar y r2 be D ec em ct o O 1 1 be t2 us ug A r2 01 01 1 11 20 ne Ju il pr A ry ua 20 20 11 11 0 01 Fe br be D ec em be ct o O Before protocol r2 01 r2 t2 A ug us ne Ju 0 0 01 10 20 10 20 A pr il y ar ru Fe b D ec em be r2 20 00 9 10 0 During protocol After leaving patient’s room Figure 4 Hand-washing rates for nurses. found between central catheter days before the PHHP (mean, 495.92; SD, 112.68) and during the PHHP (mean, 432.31; SD, 115.75), 144 (N=13) =156, P=.23. In the 2326 patients in the study during the 12-month protocol, only 1 case of CHG irritation was observed (~0.0004%). Hygiene Protocol to Reduce Hospital Acquired Infections
Raised red blotches were observed on the dorsal surface of both hands in 1 www.ajcconline.org patient after 2 days of CHG use. CHG skin irritation rates in other studies have been as high as 5.9%.21 Nurses’ Hand-Washing Compliance Results of the surveillance of nurses’ handwashing compliance were summarized in monthly percentage reports (Figure 4). Hygiene Protocol to Reduce Hospital Acquired Infections
Hand-washing compliance rates were measured and compared between AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2015, Volume 24, No. 3 221 groups and also by time of hand washing: before entering the patient’s room and exiting the patient’s room. Hand-washing compliance rates in the 12month period before the protocol was implemented were fr …Hygiene Protocol to Reduce Hospital Acquired Infections