Running head: EVIDENCE BASED PRACTICE 1

Transcription

1 Running head: EVIDENCE BASED PRACTICE 1 Evidence Based Practice Erin Burdi Ferris State University

2 Running head: EVIDENCE BASED PRACTICE 2 Abstract The growing rate of hospital acquired infections has become a major concern in our health care system. Evidence based research has shown that proper hand washing is the most effective measure health care providers can take to reduce the spread of hospital acquired infections (Bissett, 2003). Unfortunately, the lack of compliance among health care providers with recommended hand hygiene practices is startling. Compliance rates have been described to vary between 16 and 81% with an overall average of 40 %. In fact, one of the main goals of the Center for Disease Control is to provide evidence based recommendations for improvement on hand hygiene compliance ( Kampf & Kramer, 2004, para.122). The purpose of this paper is to examine evidence based research that supports the important role of hand hygiene compliance among health care professionals in the reduction of hospital acquired infections and perceived rationale behind non-compliance.

3 Running head: EVIDENCE BASED PRACTICE 3 Evidence Based Practice Health-care Associated Infections (HAIs) are the fifth leading cause of death in acute care hospitals (Stone, Hasan, Quiros, & Larson, 2007, p.279). Resistant bacteria such as Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) are becoming increasingly common (Kampf & Kramer, 2004). Doctors and nurses round from patient to patient, coming into contact with them and the surfaces in their rooms. MRSA has been isolated from the hands of up to 16.9% of health care workers. It can survive on hands for one hundred and fifty minutes and inanimate surfaces for up to seven months (Kampf, & Kramer, 2004, para.15-16). Clostridium difficile was found on 59% of health care worker s hands who were caring for an infected patient (Kampf & Kramer, 2004). Health care providers are the perfect medium for the spread of opportunistic infections when effective hand hygiene is not maintained. I am a nurse at Spectrum Health Meijer Heart Center on a cardiovascular unit. The patient population consists of a mixture of post open heart surgical patients and patients with vascular diseases. Many of the vascular disease patients are admitted with pre-existing infections of non-healing ulcers caused by their disease process. A typical nursing assignment may comprise of fresh post operative; open heart, thoracotomy, vascular bypass, and patients admitted with infected ulcers. Cross contamination infections present an infection control challenge and major concern for health care providers on the unit. Hand hygiene should be diligently maintained to prevent the spread of infection. Unfortunately, I have noticed that this is not always the case. I have chosen to review three research articles that address the important

4 Running head: EVIDENCE BASED PRACTICE 4 role of hand hygiene in reducing HAI s and examine staff rationale for non-compliance with hygiene practices. In a research study performed by Günter Kampf and Alex Kramer, the effects on nosocomial infections of hygienic hand washing, using triclosan and chlorhexidine, alcohol based hand rubs, and simple soap and water were compared. In the study of simple soap and water hand washing, 11 volunteers who washed their hands for 15 seconds with water alone 24 times per day for a total of 5 days, a slight increase of the bacterial counts was observed (mean log bacterial counts: prewash, 4.91 ± 0.46; post wash, 5.12 ± 0.44); when bar soap was used, a similar result was found (mean log bacterial counts: prewash, 4.81 ± 0.46; post wash, 5.07 ± 0.47). Transient gramnegative bacteria, such as Acinetobacter and Klebsiella, remained on the hands of health care workers in 10 of 10 cases despite five successive hand washes with soap and water. (Kampf & Kramer, 2004, para. 42) The fact that micro-organisms are merely removed, not killed, during simple soap washing may put health care workers at risk. The splashing of contaminated water while washing, combined with the condition of the sink, render this method of hand hygiene ineffective (Kampf & Kramer, 2004). Individual variations of hand washing technique and water temperature were not taken in account in this study. Hands washed with a chlorhexidine, or triclosan-based soaps can reduce the number of transient bacteria, however run the risk of bacterial resistance (Kampf & Kramer, 2004).

5 Running head: EVIDENCE BASED PRACTICE 5 Under clinical conditions, a hand wash with 1% triclosan was reported to be less effective on the total bacterial count than a 4% chlorhexidine hand wash. Triclosan was able to eliminate MRSA from the hands. In contrast, gram-negative bacteria were less likely to be eliminated after the use of triclosan. Chlorhexidine failed to eliminate MRSA from hands. However, gram-negative bacteria were more likely to be eliminated after the use of chlorhexidine. (Kampf, Kramer, 2004, para.48) The effectiveness of alcohol based hand rubs against bacterial infections were also examined and compared to prior hygiene methods. On a single ward in a 498-bed acute-care facility, use of an alcohol-based hand preparation over a 10-month period resulted in a 36% decrease in the incidence of two indicator nosocomial infections (urinary tract infections and surgical-site infections), expressed as the infection rate per 1,000 patient-days. In another study with an ethanolbased hand gel, the incidence of C. difficile-associated diarrhea decreased from 11.5 to 9.5 cases per 1,000 admissions within 1 year, but the difference was not significant. At the same time, the incidence of hospital-acquired MRSA decreased from 50 to 39%. (Kampf & Kramer, 2004, para.72) Hand hygiene compliance rates among health care providers have also improved with the introduction of alcohol based hand rubs. In summary, it was found that simple soap hand washing was better than not at all. The use of anti-microbial scrubs was found to be the most effective method of HAI prevention. Alcohol based hand rubs were found to be an effective supplement to scrubs.

6 Running head: EVIDENCE BASED PRACTICE 6 Two perceived barriers to effective hand hygiene practices among healthcare workers include skin irritation, and time pressures (Nazarko, 2009, p.65). Skin irritation seems to a major concern among nurses. Recently, I was discussing the topic of hand hygiene with a fellow RN on my unit. I will admit, she said, I don t wash my hands if I do not touch anything in the patient s room. My skin becomes dry, cracked, and peels who knows what I am exposing myself to. Our skin is the most important barrier to infection (A. Jacobson, personal communication, Oct. 16, 2009). Simple soaps and anti-microbial scrubs can strip the skin on hands of natural oils leaving them dry. Applying soap to dry hands, not thoroughly drying hands and donning gloves can also cause dry skin (Bissett, 2007). Alcohol based rubs are less irritating, but I have noticed that they leave my hands feeling sticky, a concern shared by other nurses. A recent study in Sweden found that the prevalence of skin irritation among the general public is % lower than the rate found in health care workers. As many as 25% of nurses report symptoms or signs of dermatitis involving their hands. While skin irritation is a major complaint, this study also found that skin care is not prioritized among health care providers. Health care professionals that followed a regular moisturizing routine were found to have healthier skin and improved hand hygiene. However, moisturizing lotions can easily become contaminated and become an effective medium to spread infection. Therefore, it was suggested that moisturizers either be wall mounted or pumpdispensed. (Bissett, 2007, p ) Time and workload management is a challenge that every health care provider faces. As a third shift nurse, a typical assignment varies between five and six patients. Time is a precious commodity, especially when caring for the post operative population. It is perceived among

7 Running head: EVIDENCE BASED PRACTICE 7 many health care providers that proper hand hygiene is too time consuming. When performed correctly, effective hand washing only takes approximately thirty seconds (Nazarko, 2009). Hand hygiene products should be readily available for staff to ensure compliance. In 2008, Spectrum Health implemented a wash in / wash out policy. Three crucial behaviors are expected: Hand hygiene is expected upon entering and leaving a patient s room, accountability to each other, and gratuity when reminded. Alcohol based rub dispensers have been installed outside patient rooms and in common areas to ensure ease of accessibility. Staff members were required to sign a large commitment poster that was displayed upon entering our unit. The compliance goal was set at one-hundred percent. In a recent memo from Vice President Matt VanVranken, the compliance rate has increased from eighty to ninety percent (VanVranken, 2009). Patient families have also been encouraged to use the dispensers. In fact, we are required to chart that we have discussed hand hygiene policy with patient visitors. Florence Nightingale was a pioneer in the field of nursing sanitation. She served in the Crimean War and provided care for British soldiers. Upon her arrival to the field hospitals, she found the environment filthy and lacked proper sanitation. Nightingale s work in improving these conditions made her a popular and revered person to the soldiers, but the support of physicians and military officers was less than enthusiastic (Alligood &Tomey, 2006, p72). Patient environment was a key concept in Nightingale s theory. She noted that a dirty environment (floors, carpets, walls and bed linens) was source of infection through the organic matter it contained. Even if the environment was well ventilated, the presence of organic material created a dirty area; therefore, the appropriate handling and disposal of

8 Running head: EVIDENCE BASED PRACTICE 8 bodily secretions and sewage was required to prevent contamination of the environment. (Alligood & Tomey, 2006, p75) In addition to maintaining a clean environment, Nightingale supported good personal hygiene practices. She advocated for daily bathing of patients. She required that nurses also bathe daily and wash their hands frequently (Alligood & Tomey, 2006, p76). Florence Nightingale was a visionary. She understood the concept of cross contamination from nurse to patient, and nurse to patient environment. She acknowledged the important role of hand hygiene in preventing the spread of infection in a time when this was not considered common practice (Alligood & Tomey, 2006).

9 Running head: EVIDENCE BASED PRACTICE 9 References Bisset, L. (2007). Skin care: an essential component of hand hygiene and infection control. British Journal of Nursing (BJN), 16(16), Tomey, A.M., & Alligood, M.R. (2006). Nursing theorists and their work (6 th Ed.). St. Louis, Missouri: Mosby Elsevier. Kampf, G. & Kramer, A., (2004). Epidemiologic Background of Hand Hygiene and Evaluation of Important Agents for Scrubs and Rubs. Clinical Microbiology Reviews, 17(4). doi: /CMR Nazarko, L. (2009). Potential pitfalls in adherence to hand washing in the community. British Journal of Community Nursing, 14 (2), 64-8.

10 Running head: EVIDENCE BASED PRACTICE 10 Evidence Based Practice Paper Grading Rubric Name: Erin Burdi DESCRIPTION AND ANALYSIS OF PRACTICE ISSUE POINTS POSSIBL E POINTS AWARD ED Clear Introductory Description of Practice Concern/Interest: Describes reason for interest or concern and description of issue. Practice Environment: 5 5 Provides clear description of practice area. Causal Factors: Personal Perspective and Description/Analysis of Possible Contributing or Causative Factors for the Concern Defined Area of Research Search: Narrows down and 5 5 defines a specific area for research review and provides a clear statement of same.

11 Running head: EVIDENCE BASED PRACTICE 11 RESEARCH REVIEW Research Findings: Shares the findings of a minimum 20 of 3 original research studies from professional journals 20 on the selected topic. Briefly describes the research approaches and findings of each. Critique of the Research: Attempts to point out any 5 1 research limitations/credibility of the studies. Implications For Practice: Identifies potential practice 5 4 implications of research. This goes beyond implications included in the study itself, to include perceptions of implications for personal practice. Critical Reflection: Identifies a nursing theory that this practice concern/research findings is an appropriate fit. Includes reflections on the significance/implications of integrating research into practice. STANDARDS & APA CRITERIA APA: Attaches and adheres APA checklist and APA manual guidelines. Length appropriates (5-6 pages of typed content excluding the reference page, abstract, and title page).

12 Running head: EVIDENCE BASED PRACTICE Writing: Development of a clear, logical, wellsupported paper. Overall presentation: Grammar, punctuation, clean and legible. TOTAL POINTS Well done. Great topic.

13 Running head: EVIDENCE BASED PRACTICE 13 CHECKLIST FOR SUBMITTING PAPERS CHECK DATE, PROOFREAD FOR: APA ISSUES TIME, & INITIAL 1. Page Numbers: Did you number your pages using the automatic functions of your Word program? [p. 230 and example on p. 40)] 2. Running head: Does the Running head: have a small h? Is it on every page? Is it less than 50 spaces total? Is the title of the Running head in all caps? Is it 1 from the top of your title page? (Should be a few words from the title of your paper). [p. 229 and example on p. 40] 3. Abstract: Make sure your abstract begins on a new page. Is there a label of Abstract and it is centered at the top of the page? Is it a single paragraph? Is the paragraph flush with the margin without an indentation? Is your abstract a summary of your entire paper? Remember it is not an introduction to your paper. Someone should be able to read the abstract and know what to find in your paper. [p. 25 and example on p. 41] 4. Introduction: Did you repeat the title of your paper on your first page of content? Do not use Introduction as a heading following the title. The first paragraph clearly

14 Running head: EVIDENCE BASED PRACTICE 14 implies the introduction and no heading are needed. [p. 27 and example on p. 42] 5. Margins: Did you leave 1 on all sides? [p. 229] 6. Double-spacing: Did you double-space throughout? No triple or extra spaces between sections or paragraphs except in special circumstances. This includes the reference page. [p. 229 and example on p ] 7. Line Length and Alignment: Did you use the flush-left style, and leave the right margin uneven, or ragged? [p. 229] 8. Paragraphs and Indentation: Did you indent the first line of every paragraph? See P. 229 for exceptions. 9. Spacing After Punctuation Marks: Did you space once at the end of separate parts of a reference and initials in a person s name? Do not space after periods in abbreviations. Space twice after punctuation marks at the end of a sentence. [p ] 10. Typeface: Did you use Times Roman 12-point font? [p. 228] 9. Abbreviation: Did you explain each abbreviation the first time you used it? [p ] 11. Plagiarism: Cite all sources! If you say something that is not your original idea, it must be cited. You may be citing many times this is what you are supposed to be doing! [p. 170]

15 Running head: EVIDENCE BASED PRACTICE Direct Quote: A direct quote is exact words taken from another. An example with citation would look like this: The variables that impact the etiology and the human response to various disease states will be explored (Bell-Scriber, 2007, p. 1). Please note where the quotation marks are placed, where the final period is placed, no first name of author, and inclusion of page number, etc. Do all direct quotes look like this? [p ] 13. Quotes Over 40 Words: Did you make block quotes out of any direct quotes that are 40 words or longer? [p ] 14. Paraphrase: A paraphrase citation would look like this: Patients respond to illnesses in various ways depending on a number of factors that will be explored (Bell-Scriber, 2007). Do all paraphrased citations look like this? [p. 171 and multiple examples in text on p ] 15. Headings: Did you check your headings for proper levels? [p ]. 16. General Guidelines for References: A. Did you start the References on a new page? [p. 37] B. Did you cut and paste references on your reference page? If so, check to make sure they are in correct APA format. Often they are not and must be adapted. Make sure all fonts are the same.

16 Running head: EVIDENCE BASED PRACTICE 16 C. Is your reference list double spaced with hanging indents? [p. 37] PROOFREAD FOR GRAMMAR, SPELLING, PUNCTUATION, & STRUCTURE 13. Did you follow the assignment rubric? Did you make headings that address each major section? (Required to point out where you addressed each section.) 14. Watch for run-on or long, cumbersome sentences. Read it out loud without pausing unless punctuation is present. If you become breathless or it doesn t make sense, you need to rephrase or break the sentence into 2 or more smaller sentences. Did you do this? 15. Wordiness: check for the words that, and the. If not necessary, did you omit? 16. Conversational tone: Don t write as if you are talking to someone in a casual way. For example, Well so I couldn t believe nurses did such things! or I was in total shock over that. Did you stay in a formal/professional tone? 17. Avoid contractions. i.e. don t, can t, won t, etc. Did you spell these out? 18. Did you check to make sure there are no hyphens and broken words in the right margin?

17 Running head: EVIDENCE BASED PRACTICE Do not use etc. or "i.e." in formal writing unless in parenthesis. Did you check for improper use of etc. & i.e.? 20. Stay in subject agreement. When referring to 1 nurse, don t refer to the nurse as they or them. Also, in referring to a human, don t refer to the person as that, but rather who. For example: The nurse that gave the injection. Should be The nurse who gave the injection Did you check for subject agreement? Likewise, don t refer to us, we, our, within the paper this is not about you and me. Be clear in identifying. For example don t say Our profession uses empirical data to support. Instead say The nursing profession uses empirical data Did you check your sentences to make sure you did not end them with a preposition? For example, I witnessed activities that I was not happy with. Instead, I witnessed activities with which I was not happy. 22. Did you run a Spell-check? Did you proofread in addition to running the Spellcheck? 23. Did you have other people read your paper? Did they find any areas confusing? 24. Did you include a summary or conclusion heading and section to wrap up your paper? 25. Do not use we us our you I etc. in a formal paper! Did you remove these words?

18 Running head: EVIDENCE BASED PRACTICE Does your paper have sentence fragments? Do you have complete sentences? 27. Did you check apostrophes for correct possessive use? Don t use apostrophes unless it is showing possession and then be sure it is in the correct location. The exception is with the word it. It s = it is. It is possessive. Signing below indicates you have proofread your paper for the errors in the checklist: Erin Burdi DATE:_10/21/2009 A peer needs to proofread your paper checking for errors in the listed areas and sign below: Melanie Lyon 10/20/09 Ashley Jacobson 10/21/09 DATE: Revised fall 2009

19 Running head: EVIDENCE BASED PRACTICE 19