Table of Contents
Introduction
The prevalence of hospital acquired infections (HAI) is rising (Haverstick et al., 2017). Approximately 1 in 25 patients in the inpatient setting developed an HAI at some point during hospitalization (Haverstick et al., 2017, p.1). Hospital acquired infections are costly, extend hospital stay, and have a high mortality rate. Hand hygiene is crucial in decreasing HAIs and providing high-quality patient care. Haverstick et al. (2017) states appropriate patient education on hand hygiene is equally important as staff practicing hand hygiene.
The proposed practice change is for nursing staff to provide daily teaching and reinforcement on patient hand hygiene to the patient. Patients report the need to be offered hand sanitizer or stopping at the sink to practice hand hygiene and oftentimes have difficulty doing so without assistance (Haverstic et al., 2017). Therefore, nursing staff must ensure patient accessibility to practice hand hygiene. The proposed protocol encourages patients to practice hand hygiene before and after handling wounds and/or devices, upon entering or leaving a room, before eating, and restroom use along with other specific moments (Sunkesula et al., 2015).
The national guideline being used is titled, “Infection, Prevention, and Control of Healthcare-Associated Infections in Primary and Community Care” (Agency for Healthcare Research Quality, 2013). Interventions recommended in the guideline are research-based infection control practices. The guideline proposes when to practice hand hygiene, what type of hand hygiene should be practiced, ways to prevent infections, and how to control infections. The authors utilized scholarly databases including MEDLINE, The Cochrane Library, CINAHL, PsychoInfo, and Embase (Agency for Healthcare Research Quality, 2013). Therefore, literature used to create the guideline is highly credible.
PICO
PICO stands for population, intervention, comparison, and outcome. The PICO framework provides a precise avenue to effectively answering a clinical question. For this case of nurse to patient hand hygiene education, the clinical question is: “Does reinforcement/education each day on proper hand hygiene on inpatient hospital units decrease the incidence of hospital acquired infections compared to usual education during patients’ admission and discharge?” This clinical question is broken down using the PICO framework as shown below.
P (population): Patients in hospitals’ inpatient units
I (Intervention): Daily education/reinforcement on proper hand hygiene among patients
C (Comparative intervention): Education of patients on proper hand hygiene during admissions and discharge
O (Outcome): Decreased incidences of Hospital Acquired Infections (HAIs)
Implementation
Implementation of programs for daily education on hand hygiene in hospitals’ inpatient units begin with gaining support from key stakeholder in the public health sector. Implementing daily hand sanitation programs in hospitals is a resource intensive initiative (World Health Organization, 2016). Providing tones of hand sanitizers including soaps and alcohol-based hand rubs for thousands of patients in hospitals’ inpatient units require massive funds and logistical support. Therefore, key decision makers must be notified to provide funding and other logistical supports needed to implement the hand hygiene program.
Key decision makers include the Center for Disease Control and Prevention (CDC), the World Health Organization (WHO), Federal and State health departments, Congress, and medical professionals’ associations, particularly the American Nurses Association (ANA) (The Joint Commission, 2009). The collective efforts of these stakeholders will provide the finances, personnel and logistical resources needed to commence the implementation of the daily education initiative. Once the necessary resources have been secured, the implementation process will be carried out in four phases namely: awareness creation, patient empowerment, provision of daily reminders, and role modeling.
Awareness Creation
Patients will not heed the daily reminders to clean their hands unless they understand the need to clean their hands; thus, nurses must guide the inpatients through the science and statistics behind hand hygiene. The Center for Disease Control and Prevention (CDC) provide periodic updates of best practices and health statistics on hand hygiene within hospital settings. CDC documents that averagely 12% of patients in inpatient units develop Hospital Acquired Infections during their inpatient residency. Also, CDC records that HAIs increase the medical bill for a hospitalized patient by at least 25%. Besides the high medical bill, HAIs contributes to 0.7% of deaths in the United States annually (CDC, 2017). Fortunately, HAIs can be mitigated by maintaining sound hand hygiene.
Providing patients with statistical representations of HAIs will be effective in gaining the patients’ attention during the daily education programs. Patients will start paying more attention to daily education programs after realizing that failure to wash their hands as recommended could increase their chances of death or increase their medical bills. Notably, only 32% of patients in inpatient units admitted that they had read the hand sanitation pamphlets they were given on admission; hence, indicating that provision of education once during admissions failed to promote awareness on hand hygiene among inpatients ( World Health Organization, 2017). Therefore, awareness should be created daily through the use of eye-catching brochures. In particular, nurses in at least one shift per day should deliver to each patient a brochure indicating why, when and how patients should wash their hands. The daily brochures will enhance awareness; hence, lead to increased hand washing habits among inpatients.
Patient Empowerment
Some hospitalized patients do not wash their hands at recommended rates because they are immobilized by their illnesses; hence, cannot walk to the sinks as frequently as they would desire (The Joint Commission, 2009). Other patients fail to observe frequent hand sanitation practices because they are too shy or anxious to ask the nurses on duty for soaps or directions to hand sanitation installments within inpatient units. Moreover, patients from minority ethnicities may encounter cultural marginalization from both patients and staff members from minority ethnicities in inpatient units; thus, culturally marginalized patients often fail to speak up regarding their hand washing needs (World Health Organization, 2016).
Providing daily brochures on the importance of hand washing will not necessarily increase hand washing habits, unless each hospitalized patient is empowered based on the patient’s unique needs (CDC, 2017). Empowerment approaches include discouraging cultural marginalization in inpatient units, forming interpersonal connections with shy patients, and providing portable hand washing materials to patients immobilized by their illnesses (Dawson, Garvey, Gould & McKrill, 2017). In essence, empowering patients entails providing a supportive and motivational environment in inpatient units for patients to engage in routine hand washing.
Daily Reminders
Despite the daily brochures, some patients will occasionally forget to wash their hands after using toilets, unless they are reminded frequently by the nurses on duty. Thus, reminders for hand washing should be provided at appropriate times, especially before meals. Nurses on duty should broadcast to all patients reminding them to wash their hands thirty minutes before meals are served. Also, visually appealing stickers adjacent to patients’ beds should be used to remind patients to wash their hands. Such stickers may carry messages such as, “Did you wash your hands?” or “Did you wash your hands for at least 15 seconds?” Use of daily audio and visual reminders increases the chances of patients washing their hands by approximately 41% (The Joint Commission, 2009).
Role Modeling
Hospitalized patients readily follow the health instructions issued by nurses and physicians because they want to get well soon. Besides listening to healthy instructions, hospitalized patients also observe the behaviors of medical personnel and try to emulate the behaviors (World Health Organization, 2016). In essence, nurses and physicians are authority figures revered by patients. Therefore, any habits exhibited by the nurses will be emulated by the patients. Thus, frequent hand washing among nurses per day will translate to frequent hand washing among the patients (Dawson et al., 2017). Besides exhibiting hand washing behaviors, nurses and other authority figures including nurse managers and infection control directors should visit the inpatient units and remind both junior nurses and inpatients to observe best practices in hand washing. The nurse managers may even praise junior nurses and patients who have exhibited exemplary hand washing behaviors to encourage behavioral compliance.
Evaluation
Effectiveness of the daily education on hand hygiene among inpatients can be evaluated through both direct observation and indirect observation. Direct observation entails placing a validated health observer in an inpatient unit to observe and record the systems and behaviors of hand hygiene within a unit (World Health Organization, 2016). Observers should note the strategic presence of hand washing setups, the hand washing opportunities availed to patients including the frequency of reminders and supportive infrastructure, and the timing of hand hygiene practices within an inpatient unit. The observer will subsequently compare the new observations with previous observations to determine whether or not the daily educations have improved hand hygiene practices among inpatients.
On the other hand, indirect observation entails noting the amount of hand washing materials spent by patients per given time. For example, the number of hand hygiene actions occurring in an inpatient unit per week can be estimated from the amount of hand wipes, soaps, and alcohol-based hand rubs spent within the week (The Joint Commission, 2009). Increased consumption of paper towels and soaps spent in a week represent a corresponding increase in the number of hand washing actions in an inpatient unit. Besides monitoring the consumption of hand washing materials, indirect observation also involves placing automated technologies that record the frequency of hand hygiene activities in a patient unit (World Health Organization, 2016). For example, hand rub dispensers may be installed with automated systems that count the number of dispenses in a day.
Moreover, observing changes in the incidences of Hospital Acquired Infections attributable to poor hand hygiene can reveal the effectiveness of daily education of inpatients on hand hygiene. Rise in HAIs associated with poor hand hygiene will indicate suboptimal effectiveness of the daily educational programs (The Joint Commission, 2009). On the other hand, decrease in reported cases of HAIs since the commencement of daily education initiatives will indicate optimal effectiveness of the daily intervention program.
- Centers for Disease Control and Prevention. (2017). Hand Hygiene in Healthcare Settings.
- Dawson, C., Garvey, B., Gould, D & McKrill, J. (2017). Exploring new approaches to improve hand hygiene monitoring in healthcare. Journal of Infection, Disease & Health, 22(1), 21-27.
- The Joint Commission. (2009). Measuring Handy Hygiene Adherence: Overcoming the Challenges.
- World Health Organization. (2016). WHO Guidelines on Handy Hygiene in Health Care.