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
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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
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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?
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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.
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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 metaanalysis. 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
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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).
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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
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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 Multidrugresistant organisms. American Journal for Infection Control, 35, 10, 650655. (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 multidrugresistant 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
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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.
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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
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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
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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 healthcare 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.
Method: The study utilized a “qualitative interpretive” (Barrett & Randle,
2008, p.1853) design. The researchers did this by conducting individual
interviews with 10 pre-registration nursing students in the adult, child, and mental
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health programs. Eligibility for this study included a prior clinical placement
experience (Barrett & Randle, 2008, p. 1853). The interview questions were
open-ended and the questions were the outcome of literature searches on
current topics related to barriers to hand hygiene compliance (Barrett & Randle,
2008 1852). The databases accessed for the searches were CINAHL, the British
Nursing Index, Embase, Ovid Journals, and Medline. The search terms included
‘hand hygiene’, ‘barriers’, and ‘compliance’; the results from each term were
examined as well as the result of the aggregated terms. The interview questions
were piloted with 2 pre-registration nursing students and modifications to the
questions were made prior to the individual interviews with the 10 pre-registration
students. The interviews were conducted and audio taped at the School of
Nursing. After the interviews were conducted, the information from the interviews
was compiled into overarching themes. These themes were all related to barriers
to hand hygiene within the clinical setting. There were at least two assumptions
made by Barrett and Randle (2008) in order to provide a framework for the
interview data analysis: that the information given by the students accurately
represented the “perceptions and experiences of hand hygiene in the clinical
environment” (p. 1853) and the biases and nursing experiences of the authors
would inform their decisions about which themes were to be highlighted.
Results: The authors found two major motifs that influenced the hand
hygiene compliance of these nursing students. They included ‘barriers to hand
hygiene compliance’ and ‘fit in’. Under ‘barriers to hand hygiene compliance’, the
4 specific commonalities included lack of time/ heavy workload; belief that hand
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hygiene was less important in ‘everyday’ activities such as taking a temperature;
prevention of skin compromise such as hand hygiene reluctance on the part of
healthcare workers with eczema; belief that gloves without prior hand hygiene
was an effective hand hygiene alternative. Included in ‘fit in’ was use of hand
hygiene practices that mimicked other healthcare workers, not calling out
incorrect hand hygiene practices of other healthcare workers, and utilizing
healthcare workers as positive role models for hand hygiene practice.
Conclusion and Nursing Interventions: The limitations of this study
included the small sample size and the use of a qualitative methodology, which
the authors stated, “is often criticized for its lack of generalisability” (p.1853).
While the authors stated that these were limitations, it is likely there would have
been great difficulty in attempting to ameliorate these flaws. If the authors had a
larger sample size, it would have been extremely time-consuming to find time to
conduct individual interviews with all participants. Also an increase sample size
increases the chance of variability between participants, which can decrease the
generalizability of the results. With that said, even with the small sample size
presented, the authors did not provide information of the demography of these
students for the reader. Just as the authors assume that their experiences as
nurses informed their choices and provides a certain familiarity between them
and their participants, consideration of these students foreignness to the nursing
experience and the knowledge base they use to help fill these gaps would have
been interesting.
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The authors found that the issue of hand hygiene (non) compliance was a multifaceted one and it is formed by both the actual knowledge base of these nursing
students and the situational factors surrounding proper hand hygiene. The
authors discussed the inception of the Infection Control Nurse (ICN) role and how
the ICN as well as other infection-control related healthcare workers have been
given gatekeeper roles in hand hygiene enforcement. While the authors believe
that these workers will positively impact hand hygiene compliance, the authors
note that there is still a widespread shortage of hand hygiene education and
training (p. 1855). The authors propose that the concept of “practice
development” (p. 1856) or the reintegration of hand hygiene policy into
healthcare settings in a way that takes into account the variable circumstances of
healthcare workers needs to “underpin any changes” (p.1856).
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Part III. Synthesis Paper
Compliance with hand hygiene appears to be the best form of reduction of
transmission of nosocomial infections. However, adherence to compliance is a
very subjective endeavor. A systemic review (Level I) (Picheansathian, 2004), a
case-control study (Level IV) (Bearman et al., 2007) and a qualitative study
(Level VI) (Barrett & Randle, 2008) attempt to explore compliance by health care
workers to hand hygiene. The articles did this through interviews and
questionnaires determining what practices health care workers worked the best
to prevent the transmission of nosocomial pathogens.
The case-control study, although it had a small study sample, focused on
transmission rates compared with precautions and hand hygiene compliance by
health care workers. The metaanalysis examined the ways in which health care
workers would utilize alcohol-based hand hygiene and that it was an acceptable
form of prevention. The qualitative study focused on actual hand hygiene
practices and the effect education and peer pressure had on hand hygiene
compliance. The systematic review went through an extensive amount of
scientific literature with the goal of trying to identify if alcohol-based solutions are
an effective form of hand hygiene. The research concluded that under most
circumstances alcohol-based solutions were more effective than hand-washing
alone, which helped reduce the spread of nosocomial infections. Only in
instances where hands were visibly soiled did the alcohol-based solutions not
provide an adequate form of hand hygiene. The research also noted alcoholbased solutions tended to have an increase in health care worker compliance.
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This was related to the fact that alcohol-based solutions tend to require less time
to perform effective hand hygiene, reduced skin irritations, and was readily
available for clinician use. These three factors increase HCW compliance and
could potentially help minimize the spread of infections. The overall goal of the
research was to show if alcohol-based solutions are effective. Not only is it
effective but by using this form of hand hygiene overall HCW compliancy
increased, which is a useful way to prevent the spread of infection.
In the second article, the cohort study, (Bearman et al., 2007) measured
nosocomial infection rates in patients that were initially on contact precautions
and then moved to universal precautions in a medical ICU. Several patients
developed VRE and MRSA infections despite being under contact precautions.
Follow up questionnaires found that health care workers gave less patient care to
those in contact precautions. The HCWs also felt that gloving and hand hygiene
alone were sufficient precautions to prevent the transmission of nosocomial
pathogens.
In Barrett and Randle (2008), the researchers suggest that the problem of
hand hygiene non-compliance is complex and is wrought with educational
deficiencies as well as social and resource pressures. The nursing students that
were interviewed in the study intimated the way in which a lack of knowledge
about hand hygiene (one student believed that adequate hand washing would
take 3 to 5 minutes), work pressures (this included time constraints and a heavy
workload), and social pressures (using other superior or more-experienced staff
as hand hygiene models) often function together and independently in every
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hand hygiene situational dilemma. The researchers pointed out that the
professional roles of the Infection Control Nurse (ICN) and infection control
healthcare workers (ICHW) were created in order to combat the situational
factors that these nursing students highlighted. The researchers also highlighted
that although the ICN and other ICHW roles mean well, there is a widespread
deficit of information on hand hygiene and, more specifically, the utility of hand
hygiene information and tools in the clinical setting. The researchers suggest that
any campaign that will work needs to include the information and input of the real
experiences of healthcare workers.
Conclusions and Clinical Implications: Although each article approached
the problem of hand hygiene from a different perspective it is clear that HCWs
education about the effectiveness of pathogen transmission and their perceptions
of the efficacy of hand hygiene is the deciding factor as to the rate of compliance
in a health care setting.
Nursing Implications: It is important for nurses and health care workers to
understand the risks of nosocomial infections and pathogen transmission in the
hospital. It is vital that nurses understand their role in the prevention of this
transmission through hand hygiene compliance. In the studies we found that
workload, ease of accessibility and belief in the usefulness of hand hygiene were
key factors to HCWs actually complying. Infection control staff and hand hygiene
observers in hospital settings may find it necessary to remind HCWs of the vital
importance of hand hygiene and the reduction of transmission of pathogens,
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however personal beliefs and attitudes about hand hygiene are at the core of
hand hygiene compliance.
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Part IV. Printout of Literature Search Strategies/Copies of Research
Articles