Running head: THERAPEUTIC NURSING 1 Therapeutic Nursing Intervention Jessica Hatcher Jones Old Dominion University
THERAPEUTIC NURSING 2 Therapeutic Nursing Intervention This paper will examine a clinical problem on a nursing unit; the spread of hospitalacquired infections. A seven bed Intensive Care Unit in a rural, 67-bed acute-care hospital has been chosen for analysis. This paper will further examine the clinical problem, review the current nursing practice and policies relating to this problem, and evaluate nursing interventions to formulate a plan to solve this issue. Clinical Problem In the chosen Intensive Care Unit (ICU) there is a high risk the spread of hospitalacquired infections due to a lack of adherence to contact precautions for patients with Methicillin-Resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile infections (Cdiff). Noncompliance with contact precautions is a serious problem because the unit is a small, enclosed unit and the risk of transmitting these diseases to other patients, visitors, and staff is high. This problem was chosen to be investigated because these infections have been transmitted to other patients. All patients admitted to the Intensive Care Unit are nasally swabbed and tested for MRSA. Numerous patients have been admitted and tested to be negative, only to test positive on subsequent admissions. There has also been an incidence of the patient next door to a patient positive for C-diff acquiring C-diff during their admission. In addition, patients have caught influenza, vancomycin resistant enterococcus, and even colds from being in the unit next door to a patient with the given illnesses. The two most commonly encountered reasons for contact precautions; MRSA and C-diff will be analyzed in this paper.
THERAPEUTIC NURSING 3 Current Practice Currently, the hospital uses policies based on the Centers for Disease Control s guidelines to prevent the spread of MRSA, C-diff, and other infections. The policy to prevent the spread of MRSA includes placing patients on contact precautions and in a private room, cleaning of equipment between patients or having designated equipment for that patient, wearing gloves and a gown anytime the patient s room is entered, optional face mask, and strict hand hygiene (Centers for Disease Control, 2014). The policy for C-diff is similar to that of MRSA. Patients are placed on contact precautions in a private room, gloves and gown are required every time the room is entered, equipment is to be cleaned with an approved cleanser or left in patient s room if possible, and strict handwashing with soap and water (Centers for Disease Control, 2012). The actual practice concerning contact precautions for these infections varies. With C- diff, the nurses are more diligent with following precautions. An estimated 95% of the staff follows contact precautions for patients with C-diff at all times, and almost 100% will wear at least gloves and wash their hands when working with a C-diff patient. However, for MRSA, roughly 50% of the staff follows contact precautions. Very few staff wear gowns and gloves in MRSA rooms and perform hand hygiene. Some staff will hang their gowns on the doors or save masks to reuse at a later time. Reasons cited by the nurses in this ICU for lack of adherence are ill-fitting gowns (too big or too small), the gowns are too hot, nurses feel they are being wasteful using so many gloves and gowns, and being understaffed or overworked and thus not having time to follow precautions. Additional reasons cited by nurses are that the doctors do not follow precautions and the believe they will not catch MRSA.
THERAPEUTIC NURSING 4 The above reason about not having time to gown up and wash their hands due to being understaffed is supported by a recent study. In the study by Jessee & Mion, three medicalsurgical nursing units at a magnet hospital and a community hospital were surveyed and observed concerning contact precautions (2013). Reasons given during this study for not using contact precautions were that nurses believed it took too much time to gown and glove up, heavy workload, supplies were not readily available, and lack of knowledge about precautions. The study also found through observation that the community hospital s use of contact precautions was significantly lower than the magnet hospital s (Jessee & Mion, 2013). This finding suggests a differences in hospital culture between magnet hospital and community hospitals that affects compliance with contact precautions, perhaps that is part of the issue in the ICU. Additional research has found units that are understaffed wash their hands 25 percent of the time, whereas units at appropriate staffing levels wash their hands 70 percent of the time. The same study found hospital units with staffing issues have a higher rate of infection and other negative patient outcomes (Collins, 2008). Nursing Interventions Interventions appropriate for nurses to implement will be evaluated to fix this clinical problem. In order to address the reported issues of not having enough time to gown up and being wasteful, two articles were found that suggest duct tape is the answer. In a study by Trinity Medical Center in Illinois between 2009 and 2010, a three-foot-square box of red duct tape was placed inside the doorway of isolation rooms. The goal behind the box was to create a safe zone for nurses to quickly evaluate and communicate with their patients in isolation without having to gown up. It was found that 2,700 hours and $72,000 a year were saved by this intervention (Yin, 2011).
THERAPEUTIC NURSING 5 According to Behan, Manager of Infection Prevention at Trinity Hospital, this intervention cost seven dollars per roll of duct tape and decreased social isolation of patients on isolation precautions (2012). It was also found it takes an average of 70 seconds to take personal protective equipment on and off. The red box method saved the nurse an average of 20 minutes a day. The red box intervention was also found to save an average of $9.88 per patient, per day. At Trinity Medical Center, compliance with isolation precautions went from 65 percent compliance in 2009 to 85 percent by 2012 (Behan, 2012). Implementing a red box inside each isolation room will help the ICU nurses save time, resources, and prevent the spread of MRSA and C-diff. A second intervention to decrease the spread of organisms from patients on contact precautions to other patients would be daily chlorhexidine baths for all patients. Chlorhexidine is known to kill many organisms and provide a protective barrier on skin against infectious organisms, especially Methicillin-Resistant Staphylococcus Aureus. Two Intensive Care Units at Barnes-Jewish Hospital did a study to see if chlorhexidine baths truly decreased the transmission of MRSA in their patients. Patients were swabbed for MRSA on admission, weekly, and at discharge in this study. With soap and water baths, the rate of MRSA infection was 3.84 per 1000 patient care days. With chlorhexidine baths, the rate was 2.63 per 1000 patient care days. The study found patients were 1.5 times more likely to obtain MRSA if they were bathed with soap and water than with chlorhexidine (Petlin et al., 2014). Chlorhexidine baths were also found to be effective against C-diff infections in a second study. The rate of C-diff infection was 0.41 with daily chlorhexidine baths and 1.85 with daily soap and water baths (Rupp et al., 2012). The daily chlorhexidine bath would be a viable and simple intervention to protect patients from MRSA and C-diff infections in environments that
THERAPEUTIC NURSING 6 have questionable compliance with contact precautions, such as the one under review. Patients in the ICU are already given daily baths, and chlorhexidine wipes are already available in the unit. Therefore, implementing daily chlorhexidine baths will be easy and obtainable. A third method to decrease the spread of microbes in the event contact precautions are not followed is strict handwashing or hand hygiene. A nursing intervention to increase compliance with hand hygiene is by openly observing peers, providing feedback to each other, and reminding others to clean their hands. Two studies have explored the efficacy of this method. In a study by Walker et al., (2014) these techniques increased hand hygiene compliance from 49% to 90% in one unit and 60% to 96% in a second unit. This study found a direct correlation between hand hygiene compliance and being watched. It was also recommended to provide immediate feedback, good or bad concerning hand hygiene (Walker, et al., 2014). A second source cited the Hawthorne effect, the belief that people will do the acceptable behavior when being watched, as the reason for observation being successful with increasing handwashing (Erasmus et al., 2010). Whatever the reason for the observation-feedback method s success, it would be beneficial, if used positively, in the accessed Intensive Care Unit. Feedback could be provided in the form of a gentle reminder to a coworker to wash their hands. In the event of hand hygiene success, a compliment, or a simple good job may enhance future compliance. Potential Research Study An interesting research study concerning the noncompliance with contact precautions and the spread of microbes, such as MRSA, would be to see if staff are inadvertently infecting themselves. First, all staff should be swabbed and tested for MRSA in their nares for control purposes. In the instance a staff member is positive, they should be treated. Next, each
THERAPEUTIC NURSING 7 employee should be indirectly observed concerning their contact precaution compliance over a six-month period. At the end of the six-month period, each staff member should be again swabbed and tested for MRSA in the nares. The rate of infection should directly correlate with use of contact precautions. It is hypothesized that the nurses who do not adhere to contact precautions will be colonized with MRSA and those that do adhere will not be infected with MRSA. Conclusion In a small seven bed Intensive Care Unit, there is a high risk of the spread of hospitalacquired infections due to a lack of adherence to contact precaution protocols. Infections such as MRSA and C-diff have been spread to non-infected patients in this unit. Primary reasons for the lack of adherence were time, staffing, and costs of isolation apparel. Interventions (other than isolation precautions) to decrease the spread of hospital-acquired infections include: red duct tape at isolation room doorways to provide a safe zone, chlorhexidine baths for all patients, and observation-feedback for hand hygiene. All of these interventions are feasible and would be easy to implement and effective in the Intensive Care Unit of discussion. It is also hypothesized that those nurses who do not follow contact precautions will be infected with microbes such as MRSA.
THERAPEUTIC NURSING 8 References Behan, A. (2012). The red box: A simple solution makes for a great innovation. Retrieved from http://www.ihs.org/documents/symposium/2012/presentations/am%20309%20red%20 Box.pdf Centers for Disease Control. (2012). Frequently asked questions about Clostridium difficile for healthcare providers. Retrieved from http://www.cdc.gov/hai/organisms/cdiff/cdiff_faqs_hcp.html Centers for Disease Control. (2014). Precautions to prevent the spread of MRSA in healthcare settings. Retrieved from http://www.cdc.gov/mrsa/healthcare/clinicians/precautions.html Collins, A. (2008). Chapter 41: Preventing health care associated infections. In Patient safety and quality: An evidence-based handbook for nurses. Retrieved from http://www.ncbi.nlm.nih.gov/books/nbk2683/pdf/bookshelf_nbk2683.pdf Erasmus, V., Daha, T., Brug, H., Richardus, J., Behrendt, M., Vos, M., & Beeck, E. V. (2010). Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infection Control and Hospital Epidemiology Infect Control Hosp Epidemiol, 31(3), 283-294. doi:10.1086/650451 Jessee, M., & Mion, L. (2013). Is evidence guiding practice? Reported versus observed adherence to contact precautions: A pilot study. American Journal of Infection Control, 41(11), 965-970. doi:10.1016/j.ajic.2013.05.005 Petlin, A., Schallom, M., Prentice, D., Sona, C., Mantia, P., Mcmullen, K., & Landholt, C. (2014). Chlorhexidine Gluconate Bathing to Reduce Methicillin-Resistant Staphylococcus aureus Acquisition. Critical Care Nurse, 34(5), 17-24. doi:10.4037/ccn2014943
THERAPEUTIC NURSING 9 Rupp, M. E., Cavalieri, R. J., Lyden, E., Kucera, J., Martin, M., Fitzgerald, T.,... Vanschooneveld, T. C. (2012). Effect of Hospital-Wide Chlorhexidine Patient Bathing on Healthcare-Associated Infections. Infection Control & Hospital Epidemiology, 33(11), 1094-1100. doi:10.1086/668024 Walker, J. L., Sistrunk, W. W., Higginbotham, M. A., Burks, K., Halford, L., Goddard, L.,... Finley, P. J. (2014). Hospital hand hygiene compliance improves with increased monitoring and immediate feedback. American Journal of Infection Control, 42(10), 1074-1078. doi:10.1016/j.ajic.2014.06.018 Yin, S. (2011). Duct Tape Cuts time and costs related to contact precautions. Retrieved from http://www.medscape.com/viewarticle/745502
THERAPEUTIC NURSING 10 Honor Code I pledge to support the Honor System of Old Dominion University. I will refrain from any form of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a member of the academic community it is my responsibility to turn in all suspected violators of the Honor Code. I will report to a hearing if summoned. Name: Jessica Hatcher Jones Signature: J. Hatcher Jones Date: 2/1916