The Health Service: Evidence-Based Approach on Hand Washing by Nurses - Essay Example

?EVIDENCE BASED APPROACH ON HAND WASHING BY NURSES Introduction Hammer research work proved that some bacteria such as methillin-resistant staphylococcus aureus (MRSA) have become resistant to most prescribed treatment. They are only treatable with more aggressive antibiotics and therefore strict hand washing protocols are first line defense against infection According to research conducted by Kinnula (2009) antibacterial soap is no more effective at killing germs than regular soap. Furthermore, using antibacterial soap may even lead gene mutation of the bacteria leading to growth of resistant species that persist even after the use of the product making it harder to kill disease pathogens. Further the research suggests that alcohol based hand sanitizers which do not require water are an acceptable alternative when soap and water are not available (Kinnula 2009). The product should contain at least 60% alcohol and user should follow the following steps in hand-washing: Routine hygienic hand washing for health care workers This routine was developed to ensure optimum cleaning of disease pathogens Use warm water to wet your hands Apply antiseptic soap containing chlorohexidine work up a good lather of the soap applying with vigorous contact on all surfaces of the hands especially nails and between fingers Washing should last for at least 15 seconds followed by thorough rinsing in clean water and avoid splashing Dry hands using a disposable blotting towel and discard it 1.1 Background This evidence based approach is based on studies published by centre for disease control and prevention (CDC) guideline (2002) for hand-washing and hospital environmental control that strongly recommend hand-washing using appropriate cleansing agent by care givers. The guidelines recommend alcohol-based gels as opposed to medicated soap and plain water for hygienic hand-washing by HCWs. Maintenance of a hygienic environment for the patient is recommended by WHO (2009) guidelines suggesting that clean care is safer care based on WHO patient protection policy. When microbial develop an antibiotic resistance is developed, they can be transferred and spread through bacteria strains very rapidly. Studies indicate that in England and Wales, less than 2% of Staphylococcus aureus strains were methicillin-resistant in 1990 butthis figures had changed by 2002 42% of Staphylococcus aureus strains were methicillin-resistant (Alexander 2010). An estimated 300,000 cases of hospital-acquired MRSA occur each year in England leading to 5,000 deaths. MRSA is a leading cause of death ahead of HIV, TB and viral hepatitis (Boucher 2008). MRSA infection could be reported within 48 hours of admission to a hospital (Jones 2007) resulting to 43% of all skin infections reported in U.S. In 2005 in the United States reported 368,600 hospital admissions for MRSA which included 94,000 cases of invasive infections. MRSA complications resulted in 18,650 deaths. The number of MRSA fatalities in 2005 surpassed the number of fatalities from hurricane Katrina and AIDS combined and is substantially higher than fatalities at the peak of the U. S. polio epidemic (Evans 2008). 2. Formulation of the Question (step1) 2.1 Concept of evidence based practice Evidence based practice has been with the health service for a very long time. Craig (2012, p. 5) opines that evidence based practice has existed since the early 19th century. The only difference with what is currently practiced however has to do with the fact that in those days, there was not as much documentation of the system and research on the issue as there is today. Today, it is known that evidence based practice has become a paradigm shift in healthcare work whereby service providers make use of modern best evidence in their decision making process about patient care that involves the use of the professional’s acquired expertise, patient preferences and vaules, as well as the systematic appraisal of existing research to an assigned clinical question (Bernardo, 2007, p. 375). Sackett (1996) also opines that the core mandate of an evidence based practice means “integrating individual clinical expertise with the best available external clinical evidence from systematic research." From the assertion given, there are three major thematic structures around which evidence based practice revolves and these are clinical expertise, best research evidence, and patient values and preferences. These themes can be represented diagrammatically as below: Source: Schardt (2010) In relation to the present research paper therefore, it can be said that an evidence based practice would involve a conscious effort whereby care home workers use best research evidence based on PICO questions to come out with the effect of hand washing on hospital acquired infections as ways of serving the values and preferences of patients in terms of re-infection to patients. Most often than not, health care givers have not involved themselves in evidence based practice due to a number of limitations and hindrances. In the opinion of Craig and Stevens (2012, p. 11), most of these service providers have not critical appraisal skills in differentiating between high research quality and low research quality. Meanwhile, the quality of the best research evidence is very important in achieving the overall goal of undertaking an evidence based practice. This hindrance has not made it possible for the health care givers to a fair reflection of their own good practice. Due to this, most modern day nurses and health care givers have not been part of the new shift, denying them the needed merits of using evidence based practice. With an evidence based practice for instance, it should be possible for care givers to come to a practical realization of the consequences of their actions in and out of the hospital, particularly in regards to hand washing practice. 2.2 Research Question Research questions are generally focused questions that give the researcher a scope on the kind of answers needed to attain the set research aims and objectives (quote). Research questions are particularly important in qualitative research such as the present one. The present evidence based approach is regarded as a qualitative research because it is going to involve the use of hands-on subjective data, mainly from secondary sources like literature reviews. Using a research question for such qualitative purposes generally gives the researcher an idea on the scope of literature needed to be reviewed throughout the research. It even plays a role in the selection of the article to be critiqued through out the evidence based approach. This is so because as much as possible, the article should hold answers to the research question posed. Another importance of the research question, which is generally a focused question, is that it helps in finding evidence on a generalized clinical question. For the current evidence based approach, the clinical question will be termed PICO question and will be directly rooted in the research question. Together with a well spelt out PICO question, it should be possible for the researcher to get a searchable question without necessarily resorting to the use of long and uncoordinated search schemes in finding answers to relevant pieces of evidence (diCenso, Guyyatt and Ciliska, 2005). Based on the above, the research question to guide the evidence based approach and based on which the PICO question will subsequently be set is: “Does Hand washing among Health care workers reduce Hospital acquired infection?” 2.3 PICO framework The PICO framework is undertaken to help in the course of the evidence based approach where it would lead to the setting of a PICO question. The PCIO framework is attributed to Sackett et al (1997), using it to clarify information needed from the research question in setting a single searchable question based on which subsequent data will be collected (Craig, 2012, p. 37). The PICO framework is calved from four central themes of evidence based practice including population, intervention, comparison and outcome. Generally, the population describes the group of respondents or participants who are directly affected by the question. In the present evidence based approach, the population is care givers of a selected hospital. The intervention also refers to the treatment or solution given out to curtail an immediate problem (quote). Engberg and Schlenk (2007, p. 572) state that the intervention is the “description, which may include treatments, test, risk factor, exposure or patient observation.” In the current situation and based on the research question, the intervention can be found to be the practice of hand washing. Comparison on the other hand refers to a control or alternative intervention which is expected to yield a contrasting result. Even though it can commonly be omitted, the present research question could have a comparison of hand washing noncompliance. Finally, the outcome makes use of the desired result of using the intervention. Commonly, the outcome is expected to be evidenced on the population. Invariable, the desired result of applying the indicated intervention is reduced hospital acquired admissions. In sum, a PICO question can be derived from the PICO framework as “Is hand washing noncompliance among care givers the cause of increased hospital acquired admissions?” The question satisfies the PICO framework in the following manner: Population Intervention Comparison Outcome Health care workers, resident patients Hygienic hand-washing Non-compliance to hand-washing Reduced HAI infection with MRSA 3 Finding the Evidence (step2) 3.1 Structuring the Search Having set the PICO question and the research question, it was important to find an article that best addresses the issues raised in the two questions. The need to find such an article is in compliance to the provisions of qualitative research, which makes use of secondary data as opposed to primary data (quote). Such secondary data are expected to be the research works of other researcher who have studied topics that are related to the present area of study. But because the use of secondary data has generally been criticized on issues of validity and reliability due to the fact that the researcher does not have first hand access to the data that the secondary data presents, it is always important to ensure that a comprehensive search structure will be designed. Such search structure makes it possible to have an inclusion and exclusion criteria used to critically examine the sources that are identified and the article that will eventually be selected (quote). Having said this, it would be stated that structuring the search involved the design of two major literature logs. The first was an evaluation table, which gave room for the researcher to sample as many articles as possible based on the headings below. Authors/Year of Citation Research Design Data Collection Methods Sample Characteristics Key Findings A detailed evaluation table has been presented at the appendix section of the paper. The other form of literature log was a methodological matrix and evaluation matrix. The methodological matrix and evaluation matrix also contained the following headings: Author Pub Year Country Theory Dependent Variables Independent Variables Study Design Sample Size Sampling Method How data collected 3.2 Conducting the search The search was conducted with the two literature logs referred to above. With these two literature logs, it the researcher achieved two major goals. The first was that it was possible to identify the best articles that contained data on the research question and thus rightly addressed it. Secondly, it was possible to sample articles that could be trusted as genuine, reliable and with valid data. The search started with an idea of getting 50 initial articles. These 50 articles were selected from sources including books, journals, internet websites and health encyclopedias. The first selection process involved a skimming exercise undertake through the contents of the articles. That is, the researcher skimmed the contents to be sure that they had topical issues that touched on hand washing by health workers. Even before, a generalized selection criterion was to ensure that there were only health related sources were included. The skimming exercise was what led to the selection of the 50 articles. After the skimming exercise, a scanning process was undertaken through the paragraphs and some contents of the 50 articles. This was done with a purpose of selecting 20 best articles that matched the inclusion criteria on the research designs being used by the various researchers in the articles. The research designs were supposed to be case study, action research, Meta analysis or survey. These were selected as they are generally more aligned to evidence based approaches (quote). The sample characteristics were also taken into key consideration in the inclusion and elimination process as the researcher attempted to include only articles that touched directly on health workers as part of their sample characteristics. Through this, the 20 articles were selected. 3.3 Results Having collected 20 articles, the researcher was very close to getting the final article that would be the most preferred source for undertaking the evidence based approach. As a matter of fact, almost all 20 articles were considered to be good enough. For this reason, very straight forward process was used to slash the number down to 10. This process was by using the dates of publication whereby the 10 latest articles were included. Having had 10 articles, the researcher undertook a thorough reading of all the 10 articles to come to terms with the single one of the 10 that best addressed the PICO question that had been set. After the reading, the resulting article selected was an article by Keith, Deverick and Keith (2010). A brief annotation of the article can be given as indicated below Keith I C, Deverick J. A and Keith S. K, 2010, Hand Hygiene Noncompliance and the Cost of Hospital Acquired Methicillin-Resistant Staphylococcus aureus Infection. Infection Control and Hospital Epidemiology. April 2010. Vol. 31 No. 4 The work of Keith, Deverick and Keith (2010) was selected with the background of the authors in mind. It was identified that these were writers who had for the past decade contributed on a constant basis to the journal to which they write for. This level of consistency guarantees the degree of maturity, reliability and validity associated with the works they produce. This is because the Infection Control and Hospital Epidemiology is a highly respected outfit that works only with tried and tested writers. Moreover, the topic of related directly to the PICO framework of the evidence based practice being carried out. This is because in terms of population, the population of the article touched on health workers. On intervention, their intervention dealt with hand hygiene. On comparison, their alternative dealt with noncompliance, whiles on outcome, their outcome dealt with reduced hospital related infections. 4 Evaluating the evidence (step 3) 4.1 Description of the study The study centered on undertaking a mathematical simulation of sequential patient contact by two major health workers. Both health workers were non-complaint to hand hygiene provisions. However, whiles one of the health workers had encounter with patients with unknown Methicillin-Resistant Staphylococcus aureus (MRSA), the other hand encounter with patients with colonized MRSA. The study was conducted at Duke University Medical Center, which has a 750 bed capacity with a high level of occupancy at all times. The setting was thus ideal for obtaining all levels of data on the MRSA state of patients as well as the use of the mathematical simulation. Generally, the study made use of a mixed research approach whereby a combination of primary and secondary data were used. This is because data from existing published reports were intermittently used. Ultimately though, primary data were collected from the health workers who acted as respondents on their daily contact between patients and HCWs and the average length of hospitalization per resident patient (Keith, Deverick and Keith (2010). This was related to the quality improvement studies previously conducted by at Duke University medical and this gave the study its mixed approach format as secondary and primary data were used together. 4.2 Critical Evaluation of the Methodology Undertaking a critical evaluation is a professional “process of assessing and interpreting evidenceby systematically considering its validity, results and relevance” (Parkes et al 2001 p.10). This could be undertaken in a number of ways depending on the area of study to be critically assessed. For the methodology, the critical evaluation shall be undertaken by using the critical appraisal skills programme (CASP). This is an evaluation tool made up of 10 questions. The 10 questions constitutes three major components of assessment namely validity, results and relevance. What this means is that the validity, results and relevance of methodology used in the selected article is what shall be assigned to critical scrutiny. In the present situation, validity of the methodology shall be analyzed in two major formats, which are internal validity and external validity. Internal validity involves the relation between results and variables to ensure that results are not based on bias or error. In a direct relation, external validity deals with avoiding the use of invalid results in a trial (Gerrish and Lacey 206, p. 536). Given the study undertaken by Keith, Deverick and Keith (2010), it can be said that internal validity was achieved because selection of variables was not based on any pre-conceived motives that could affect the respondents included in the study. However external validity could be threatened as researchers undertook no pre-interventional data collection to ensure that respondents were not coming into the study with any known cases of infections. Meanwhile, there were only single episodes of non-compliance, which means that others could actually be affected even before the study. The stochastic mathematical model was used in measuring the results. A major strength of using this mathematical model is its ability to factor out odd ratios, which otherwise would have been neglected in using other forms of measurements. This means that accuracy of the results could be guaranteed from the methodology used; especially in terms of the computations performed on the numbers collected. This notwithstanding, there was an alternatie model, which does not befit the said advantages. This is because the alternative model includes environmental factors in MRSA transmission hence it is based on total number of room visits instead of physical contact between HCWs and patients. Generally, relevance of the methodology could be scored above average particularly as the researchers used a combination of methods including extraction of data from existing publications. 4.3 Results Prevalence of MRSA was determined as 4.63%- 4.72%given within 95% confidence interval. Transmission of MRSA associated with noncompliance to hand hygiene was estimated at 1.43%.compliance to hand hygiene after room visit by HCW was at 45.1% while majority of patients were admitted to hospital stayed in enclosed rooms. However HAI cannot be attributed exclusively to contact with HCW s but contaminated environment is likely to cause infection. There is no existing study on the cause of cost of contaminated hospital environment associated with MRSA infections. Analysis of normal and high risk scenario based on the 4 Boolean variables Variable Normal scenario(model1) High risk scenario(model2) Patient 1 colonized by MRSA 0.0463 1.0 Patient 2 colonized 0.9537 0.9537 Colonization 0.0036 0.0036 Infection per colonization 0.29% 0.29% Cost per infection(95% confidence interval) $7228-164392 $7228-164392 Model 1 was associated with 42 MRSA infections (infection rate, 0.0042%). Mean infection cost was $47,092 (95% confidence interval [CI], $26,040-$68,146); mean cost per noncompliant event was $1.98 (95% Confidence Interval, $0.91-$3.04). Model 2 was associated with 980 since patient 1 was assumed to be MRSA infections (0.098%). Mean infection cost was $53,598 (95% CI, $50,098-$57,097); mean cost per noncompliant event was $52.53 (95% CI, $47.73-$57.32). the hypothetical 200-bed hospital would $1,779,283 in annual MRSA infection-related expenses attributable to hand hygiene noncompliance. A 1.0% increase in hand hygiene compliance resulted in annual savings of $39,650 to a 200-bed hospital 5 Recommendations (step4) Based on the evaluation of evidence and methodology undertaken, there are three major recommendations suggested in relation to the study. 1. A pre-intervention data collection about respondents should always be an important way of ensuring external validity so that results will not be influenced by already existing variables. 2. The use of secondary and primary data collection processes should not be combined in the presentation of results so that clearly distinction shall be made on the outcomes from the two data collection methods. 3. There should be more than one episode of non-compliance so that there can more room for comparison of outcomes. 6 Application of Evidence (step 5) 6.1 Implementation of change The changes to be implemented are based on the recommendation that there should be change in practice to include more episodes of non-compliance so that there could be more room for evidence comparison. Generally, the basic objective of evidence based practice is ensuring patients get the best remedy possible for their condition. Embracing this EBP objective in practice demands that HCWs place patient needs ahead of any other activity and doing so involves taking caution such as observing hand hygiene. Common opinion among HCWs urges that it is unethical to use treatment methods that haven’t been tried previously. However services may need to be individualized to meet unique patient conditions. In this case being informed of “what works" in general may not be the most salient factor in serving such a client (Olswang 2009). The evidence based change that will be enacted will be based on the England standard principles. This therefore brings to the next sub-section on principles of evaluating change. 6.2 Principles of evaluating change According to Denham (2001) England on standard principles for preventing hospital acquired infection could be achieved through maintenance of a hygienic hospital environment. England national guidelines are classified into three major standards 1. Hospital environment hygiene 2. Hand hygiene 3. Use of personal protective equipments (Denham 2001) The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding hand-washing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings 6.3 Audit Gerrish and Lacey (2006, p. 534) argue that audit deals with a structural approach undertaken to measure and improve practices and outcomes in consolidation with standards set at both the local and national levels. Already, the principles or standards to be used for auditing has been identified to be the England standard principles. Based on these, a guaranteed way of ensuring improvement in practice would be through the proper screening of patients. Screening patient before admission provides vital information on unique care required when handling specific patient. In implementation of prior screening HCWs should be informed of the body parts that have high vulnerability to MRSA colonization and health conditions that make a patient vulnerable to pathogen colonization: infected/draining wound, skin, perennial areas, axillae, trunk and upper extreme –hands are highly colonized. . Diabetic patients, chronic renal failure patients undergoing dialysis and those with chronic dermatitis are highly vulnerable infection. Other items within contact with the patient like beddings, clothes, taps and faucet they can facilitate the spread of MRSA. Research conducted by WHO (2009) indicated that 29% of clinicians working at general hospital and 78% of those working at a demagogical unit had their hands infected with bacteria and continued the infection chain. EBP procedures provide the alternative of home care after a patient has stabilized especially due to rising demand for health care and economic constrains on the patient. This can be utilized as an avenue to reducing unnecessary hospitalization which predisposes a patient to hospital acquired MRSA infection. The alternative of home care reduces infection probability. As observed there were a high risk of colonization within 48 hours of hospital admission and the average stay at the hospital being rated at 6.26 days per patient. Flexibility in service provision greatly reduces these values. Conclusion Screening patient before admission provides vital information on unique care required when handling specific patient. In implementation of prior screening HCWs should be informed of the body parts that have high vulnerability to MRSA colonization and health conditions that make a patient vulnerable to pathogen colonization: infected/draining wound, skin, perennial areas, axillae, trunk and upper extreme –hands are highly colonized. . Diabetic patients, chronic renal failure patients undergoing dialysis and those with chronic dermatitis are highly vulnerable infection. Other items within contact with the patient like beddings, clothes, taps and faucet they can facilitate the spread of MRSA. Research conducted by WHO (2009) indicated that 29% of clinicians working at general hospital and 78% of those working at a demagogical unit had their hands infected with bacteria and continued the infection chain. EBP procedures provide the alternative of home care after a patient has stabilized especially due to rising demand for health care and economic constrains on the patient. This can be utilized as an avenue to reducing unnecessary hospitalization which predisposes a patient to hospital acquired MRSA infection. The alternative of home care reduces infection probability. As observed there were a high risk of colonization within 48 hours of hospital admission and the average stay at the hospital being rated at 6.26 days per patient. Flexibility in service provision greatly reduces these values. It is necessary that patient beware of their rights to quality service without being exposed to unnecessary risk of HA-MRSA infection. Health care awareness education among patients should be conducted empowering them to take proactive role in ensuring they receive service as recommended with patient recovery being a priority. Patients should be aware of their MRSA status before admission and when being discharged to take necessary measures in managing their condition and avoid unnecessary complications. REFERENCE LIST Alexander .A, 2010. Hospital Acquired Methillin Resistant Staphylococcus Aureus. Viewed on 5th Jan, 2013 at http://microbewiki.kenyon.edu/index.php/Hospital-acquired_Methicillin_Resistant_Staphylococcus_Aureus_%28MRSA%29 Bernardo, L.M. (2007) Evidence- Based Emergency Nursing Practice: The Journey Begins. Journal of Emergency Nursing 33:4 (375-376). Emergency Nurses Association. Bravo.D.F. &Earls J.A.&Johnson.A.A, 2011. Relationship Between Hand Hygiene Compliance and Nomsocomial infection. Duke university Craig, J.V (2012) How to ask the right question in Craig, J.V & Smyth, R.L (Eds) The Evidence Based Practice Manual for Nurses. 3rd ed. London: Churchhill Livingstone. Craig, J.V and Stevens, K.R. (2012) Evidence based practice in Nursing in Craig, J.V & Smyth, R.L (Eds) in The Evidence Based Practice Manual for Nurses. 3rd ed. London: Churchhill Livingstone. Cumming .K. & Olswang B.L, 2009. Clinical Methods: Evidence-Based Practice Finding existing evidence)” http://faculty.washington.edu/lolswang/html/500/500%20EBP.pdf Denham .J, 2001. The epic guidelines for preventing health care associated infections http://www.puricore.com/PDFs/Guidelines_for_Preventing_Healthcare.pdf Deverick. J.A & Keith.S.K, 2010. Hand Hygiene Noncompliance and the cost of Hospital Acquired Methillin Resistant Staphylococcus Aureus Infection DiCenso, A., Guyatt, G. and Ciliska, D. (2005) Evidence- based nursing. A Guide to clinical Practice. St.Louis. Mobsy, Inc. Gerrish, K. and Lacey, A. (eds) (2006) In The research process in Nursing. Oxford. Blackwell Publishing Ltd. Hammer,S. 2012. Handwashing :Reducing Nosocomial Infections.Ithaca:Cayuga Medical Centre. LeTexier. R, 2000. Preventing infection through hand-washing. Infection control today http://www.infectioncontroltoday.com/articles/2000/07/preventing-infection-through-handwashing.aspx LoBiondo –Wood.G. & Haber.J, 2009. Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice Elsevier Health Science Ontario Public Health Libraries, 2008. Critical appraisal of research evidence Parkes (2001) cited in Booth, A. (2006) Critical appraisal of the Evidence. In Gerrish, K. and Lacey, A. (eds) In The research process in Nursing. Oxford. Blackwell Publishing Ltd. Sackett, D. Evidence-based Medicine - What it is and what it isn't. BMJ 1996; 312:71-72. [Online] http://www.bmj.com/cgi/content/full/312/7023/71 [January 5, 2013] Schardt C. 2010. Introduction to Evidence Based Practice. [Online] http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm [January 5, 2013] Smith.S., 2012.Evidence based practice journal http://sophia.smith.edu/~jdrisko/evidence_based_practice.htm WHO, 2009. Guidelines on hand hygiene in health care: first global patient safety challenge. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf APPENDICES Appendix 1 Evaluation table Authors/Year of Citation Research Design Data Collection Methods Sample Characteristics Key Findings Keith, Deverick and Keith 2012 Case study Mixed research made up of qualitative and quantitative research The research was conducted at Duke University medical centre which has a 750 -bed capacity where 42 MRSA infections and 980 MRSA infections were used respectively for models 1 and 2. Hand hygiene non-compliance is associated with significant attributable hospital cost. Appendix 2 Methodological Matrix and Evaluation Matrix. Author Pub Year Country Theory Dependent Variables Independent Variables Study Design Sample Size Sampling Method How data collected Keith, Deverick and Keith 2010 England Hygiene non-compliance Cost per infection Patient colonization Case study 1022 Random sampling method The simulation method applied four Boolean variables to define a single path of hospital acquired MRSA. these were: probability of patient 1 being MRSA positive, probability of patient 2 being MRSA negative, probability that cross-contamination occurs leading to colonization of patient2 by MRSA and the probability that the colonization lead to infection. Though this data gives values close to the real situation it ignores other factors/paths that MRSA infection could occur though. Pathogen cross transmission is a complex process and defining it into a single path underestimates time and level of colonization. Appendix 3 Read More