Effectiveness of a Hospital-Wide Program to Improve Compliance with Hand Hygiene by Pittet et al - Article Example

Unit 8 Project: Analysis of a Research Study Paper HS 305 -03 Ellen Weston Analysis of a Research Study. Introduction The article by Pittet et al. was chosen because it deals with an aspect of healthcare practice which is both extremely simple, namely hand washing in a clinical setting, and yet extremely difficult to implement in a thorough and effective way. All health care professionals learn about the importance of hand washing as a tool to be used against the spread of hospital acquired infections such as MRSA. Despite this, modern hospitals still struggle to keep their levels of infection down, and to ensure that appropriate and above all effective hand washing policies are implemented across the board. I have observed both good and bad practice of hand washing in my career so far and this has motivated me to reflect more on the issue and try to understand why this is still an issue despite all the knowledge, initiatives and resources that have been devoted to its improvement. The problem that the researchers faced was to evaluate the introduction of a hospital wide initiative designed to promote hand hygiene. There was an awareness that compliance with such directives is often quite poor. The challenge of the research was to examine how the programme was received by staff, whether it changed their behaviour for the better, and ultimately how much this initiative contributed to the hospital’s targets on reducing nosocomial infections. There was a special emphasis on the introduction of bedside, alcohol-based hand disinfection, and the team wanted to evaluate whether this was as good as or better than traditional soap and water hand cleansing. On the face of it this appears to be quite a trivial matter, but in fact the problem of hospital acquired infections is rising across the world, and the number of bacteria which are resistant to antibiotics is also rising. There is little point in investing large sums of money in excellent clinical care if the patients are harmed by serious infections while receiving treatment. Likewise, there is little point in setting up expensive initiatives, with specially trained leaders, liaison groups and publicity budgets if they do not achieve any real improvement. This study examines all of those factors and aims to provide hard evidence on how hand washing behaviour is affected by such an initiative, and whether this has the desired benefit for patients. Design of Study The study was designed longitudinally over the period from December 1994 to December 1997, and states that the fieldwork aimed to “monitor the overall compliance with hand hygiene during routine patient care… before and during implementation of a hand-hygiene campaign.” (p. 1307) It was important to establish a base line at the outset, so that any improvement could be measured over time. The setting is a teaching hospital in Geneva, Switzerland. The main method used in the study is hospital-wide observations which were carried out twice annually, during designated periods of 20 minutes over a 2-3 week period each time. This method provides in-depth information about these short periods of analysis and covers a wide range of different staff and patient types, and clinical settings. The recording of data was done by nurse observers, as unobtrusively as possible, but the observers were not hidden. There is a possibility that the presence of observers affected the results. Parallel to this focus on the behaviour of staff there is also some hard data analysis. The amount of alcohol based cleanser being used was monitored, reflecting a rising trend, The team also tracked instances of different infection rates over the period covered by the study. These are straightforward numerical comparison method and they provide clear evidence of improvement. The researchers acknowledge, however, that it is very difficult to identify how far the hand washing initiative was responsible for this, and how far other factors were involved such as changes in antibiotic drug used or dosages given to patients. One issue which was not covered was that of the quality of the hand washing activity that was recorded. A study on hand washing techniques by Larson and Lusk (1985) identifies this as important, and advised that self –reporting via questionnaires and short spells of observation may not give an accurate picture. Other methods such as clandestine observation, and observation over a long period are methods which are suggested as improvements, because they are both more accurate and less likely to affect the actual behaviour of hospital staff. There are, of course, ethical issues in connection with the first method and cost implications associated with the second, but these two methods could address some of the weaknesses identified in the Pittet et al. study. Ethical Standards There were a number of ethical concerns in this study, and one of those was the need for sensitivity towards staff who were observed. Normally human subjects would be asked to give permission before they become involved in research projects. In this case, however, the hospital management approved the research and made it a hospital priority which meant that employees had no choice regarding participation or non-participation in the study. The proposal was submitted to the institutional review board and the researchers undertook not to identify staff members observed by any unique identifier. It is unclear whether the demographics of the staff and the noting of locations or other details of the observations would compromise staff anonymity. The in-house nature of the whole study made it easier for the team to conduct its fieldwork, but on the other hand it does raise questions about objectivity and the right of individuals to opt out of research if they want to. The researchers considered the potential benefits of using a randomization method, or control groups, but rejected these two possibilities because of possible harm that could come to patients. It appears, therefore, that ethical factors standards were upheld at the design stage of the study. A third area of ethical standards was that of the observer’s responsibility (or otherwise) to point out any potentially serious hand washing errors or omissions that could harm patients. There is no evidence that the observers attempted to remind staff to wash their hands, even in situations where there was high risk of infection transfer. Generalized feedback to the staff was given after each spell of observations, but this does not address particular observed incidents, and this may have contributed to risks being passed on to patients. Conclusions The Pittet et al. study did achieve its aim of documenting and assessing a hospital wide initiative over three years. It produced clear evidence that hand hygiene behaviour changed over this period, showing no change in the amount of soap and water cleansing, but a big increase in the amount of hand cleansing using alcohol based solutions in dispensers. Most health care workers increased their level of hand washing, and the overall compliance rate shifted from 47.6% in 1994 to 66.2% in 1997. There was a glaring exception, and that was the doctors, but there was little discussion of this point, beyond recommending more training. The researchers admitted that “the best way to improve hand hygiene among doctors remains to be determined” (p. 1311) One does wonder, also, happened in that hospital in the 45 or more weeks of the year when no observers were present, and how long-lasting the positive effects proved to be. Despite these reservations, this study did achieve its aim of tackling the issue of hand washing in a multi-modal way. It successfully engaged with hospital management, hygiene teams, performance monitors and all kinds of hospital staff, to produce a positive evaluation of the hospital’s initiative over the three year period in question. An important finding was that the use of bedside hand rub dispensers did encourage better hand hygiene for most hospital staff groups. References Larson, E. and Lusk, E. (1985) Evaluating handwashing technique. Journal of Advanced Nursing 10, 547-552. Pittet, D., Hugonnet, S., Harbarth, S. et al. (2000) Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet 356, 1307-1317. Available online at: http://www.medlinegroup.com/sterillium-comfort-gel/pdf/Effectiveness%20of%20a%20hospital-wide%20programme%20to%20improve%20compliance%20with%20hand%20hygiene.pdf Read More