EBP: Handwashing Intervention

Evidence-Based Practice Project- Handwashing Intervention
Student’s Name
Institution
Abstract
Evidence-based practice (EBP) has the potential to improve patient outcomes and attain the desired benefits for different stakeholders in the healthcare sector. This project proposes a handwashing intervention to reduce hospital-acquired infections (HAIs) in the Intermediate Step Down Unit at John Hopkins Hospital in Baltimore, Maryland. An organizational assessment of the hospital showed that it is ready for change. The project seeks to answer the PICOT question: does handwashing as compared to non-hand washing and hand sanitizer utilization amongst health care workers and patients reduce HAIs amongst patients during their admissions in the hospital? A literature search provided relevant and valid evidence to suggest that a handwashing intervention in the organization can reduce HAIs. The intervention involves a three-step handwashing procedure which is simpler compared to WHO’s 6-step guideline. The implementation will be carried out for three months with Rogers' diffusion of innovation theory being used as the change model. It is expected that a significant reduction of HAI rates will be observed in the Intermediate Step Down Unit after the implementation of the project.
Table of Contents TOC \o "1-3" \h \z \u Abstract PAGEREF _Toc23772469 \h 2Section A: Organizational Culture and Readiness Assessment PAGEREF _Toc23772470 \h 5Section B: Problem Description PAGEREF _Toc23772471 \h 6PICOT PAGEREF _Toc23772472 \h 6Background of the problem PAGEREF _Toc23772473 \h 7Rationale for Nursing PAGEREF _Toc23772474 \h 8Stakeholders PAGEREF _Toc23772475 \h 8Section C: Literature Support PAGEREF _Toc23772476 \h 9Section D: Solution Description PAGEREF _Toc23772477 \h 13Proposed Solution PAGEREF _Toc23772478 \h 13Organization Culture PAGEREF _Toc23772479 \h 14Expected Outcomes PAGEREF _Toc23772480 \h 14Methods to Achieve Outcomes PAGEREF _Toc23772481 \h 15Outcome Impact PAGEREF _Toc23772482 \h 15Section E: Model of Change PAGEREF _Toc23772483 \h 16Stages PAGEREF _Toc23772484 \h 16Categories PAGEREF _Toc23772485 \h 17Section F: Implementation Plan PAGEREF _Toc23772486 \h 18Setting PAGEREF _Toc23772487 \h 18Timeline PAGEREF _Toc23772488 \h 18Resources PAGEREF _Toc23772489 \h 19Methods and instruments PAGEREF _Toc23772490 \h 19Intervention delivery PAGEREF _Toc23772491 \h 20Data collection PAGEREF _Toc23772492 \h 20Feasibility PAGEREF _Toc23772493 \h 21Post-implementation PAGEREF _Toc23772494 \h 21Section G: Evaluation of Process PAGEREF _Toc23772495 \h 21Rationale for Methods PAGEREF _Toc23772496 \h 21Outcome measures and project objectives PAGEREF _Toc23772497 \h 22Measurement and evaluation of outcome PAGEREF _Toc23772498 \h 22Negative results strategies PAGEREF _Toc23772499 \h 23Implications for practice PAGEREF _Toc23772500 \h 23References PAGEREF _Toc23772501 \h 25Appendices PAGEREF _Toc23772502 \h 28Appendix A: Critical Appraisal Checklist PAGEREF _Toc23772503 \h 28Appendix B: Evaluation Table PAGEREF _Toc23772504 \h 29Appendix C: Conceptual Model PAGEREF _Toc23772505 \h 31Appendix D: Timeline PAGEREF _Toc23772506 \h 32Appendix E: Resource List PAGEREF _Toc23772507 \h 33Appendix F: Proposal Instruments PAGEREF _Toc23772508 \h 34Appendix G: Data Collection Tools PAGEREF _Toc23772509 \h 35Appendix H: Budget PAGEREF _Toc23772510 \h 36
Section A: Organizational Culture and Readiness Assessment
Assessing an organization’s culture and readiness for change is vital before EBP implementation. This section uses a tool for assessing organizational readiness for implementation of EBP by Austin and Claassen (2008). The tool is made up of four components that include organizational capacity, staff capacity, organizational culture, and implementation plan. The tool helps in determining the organizational strengths and the areas that need development.
The results of the survey indicate that the level of readiness in the organization is high in regards to organizational capacity and culture; however, staff capacity and implementation require development. With the highest score being 20 and lowest being 4, the organization scored 17 in organizational capacity. It is deducible that the organization is ready when it comes to capacity. Leadership from top management in the organization support designated change and its mission is linked to EBP implementation. Furthermore, there are adequate financial resources in the organization to facilitate EBP implementation. The score of 16 in organizational culture is supported by trust and cohesiveness, open communication, and an understanding of mission and goals among staff members.
With a score of 12, it is deducible that the implementation plan component requires development. In this regard, a lack of a mechanism of the involvement of all staff and a cohesive team of implementers can be a barrier to the implementation of EBP.
The integration of clinical inquiry into the organization can be done through promoting a culture of inquiry as well as setting up supportive infrastructure (Bryant & Schiavenato, 2016). The strategies that can help improve the implementation component of the organization include developing a mechanism to include members of the organization at all levels and establishment of a trained and oriented team of implementers.
Summary of Results
Component

Score

Organizational Capacity

17

Organizational Climate/Culture

16

Staff Capacity

13

Implementation Plan

12

Section B: Problem Description
Hospital Acquired Infections (HAIs) is a key problem facing the US healthcare. This project seeks to examine how handwashing among healthcare workers and patients can reduce HAIs.
PICOT
Population- Inpatients and patients at John Hopkins Hospital, Baltimore, Maryland Intervention- handwashingComparison- non-handwashing and utilization of hand sanitizerOutcome: Reduced HAIs Time: Hospitalization period PICOT Question : Does hand washing as compared to non-hand washing and hand sanitizer utilization amongst health care workers and patients reduce HAIs amongst patients during their admissions in the hospital?
Background of the problem
According to the Centers for Disease Control & Prevention (CDC), it is estimated that there were 687,000 HAIs in acute care hospitals in the US in 2015 with 72,000 dying during their hospitalizations in the same year (CDC, 2018). HAIs are not only common in healthcare settings, but they are also among the top 10 leading causes of death in the country. In advanced countries such as the U.S., for every 100 patients hospitalized, 7 acquire HAIs (Haque, Sartelli, McKimm, & Bakar, 2018). In a study involving 11, 282 patients and 183 hospitals in the US, it was found that 4% of patients had at least 1 HAI (Magill, et al., 2014). The researchers in the study approximated that in 2011, there were 648,000 patients in the US that had HAIs. With these statistics, it is evident that HAIs constitute a major healthcare problem that poses a significant threat to public health. According to Ceballos, Waterman, Hulett, and Makic (2013), infants that acquire HAIs spend more days in hospitals and mechanical ventilation. This translates to high costs and mortality compared to those without infections. It is deducible that HAIs is a key issue affecting US healthcare and therefore it deserves attention.
As a practice issue, low hand hygiene compliance rates among healthcare personnel accounts for high HAI rates in hospitals. As informed by Sickbert-Bennett et al. (2016), an improvement of 10% in hand hygiene among healthcare personnel results in a 6% drop in HAIs rates. Hand hygiene interventions have been shown to significantly reduce HAIs rates. Another study by O’Donoghue, Suk-Hing Ng, & Boost (2016) examined how education and provision of resources such as alcohol-based hand rubs (ABHR) impacted compliance. There was significant increase in compliance rates in the study. Furthermre, Haverstick et al. (2017) show that provision of education and hygiene materials for patients significantly reduces HAIs.
Rationale for Nursing
The issue of HAIs is significantly important for nursing because nurses handle patients directly and contribute to the prevalence of the problem. In this sense, they are best positioned to collaborate with other healthcare stakeholders to reduce the incidences of HAIs. According to Ceballos, Waterman, Hulett, and Makic, (2013), while other healthcare professionals can follow guidelines to reduce HAIs, nurses are more consistent and empowered to lead change interventions. Nurse quality improvement leaders can educate providers, track compliance, report patient outcomes, and advance improvement strategies (Ceballos, Waterman, Hulett, &Makic, 2013). In this sense, nurses are well-positioned to address the HAIs issue. Furthermore, according to a study by Boev and Xia (2015), a collaboration between nurses and physicians is associated with better HAI outcomes. The study shows that increased collaboration between nurses and physicians results in a decrease in bloodstream infections and pneumonia. This further proves that nursing has a vital role to play in addressing the issue of HAIs.
Stakeholders
An implementation of this project will affect a number of stakeholders including patients, healthcare organizations, the federal government, physicians, insurance providers, and nurses. With the aim of reducing HAIs, patients will benefit from the resulting lower levels of the infections. Given that hospitals are settings that HAIs primarily occur in, they will benefit in regards to reputation if the problem is addressed. Federal agencies such as the CDC will gain data and information that will help in addressing the problem. The federal government may also be interested because the project has the potential to reduce healthcare costs associated with HAIs. With reduced incidents of HAIs, physicians and nurses can direct their efforts to other healthcare issues.
Section C: Literature Support
The following databases were searched comprehensively for articles:
ProQuest,
PubMed Central
Google Scholar.
The search criteria included English articles published between 2013 and 2019. The keywords used in the search included:
Hospital-acquired infections,
Health-care-associated infections,
HAIs,
HCAI.
Each of the above keywords was repeated in combination:
Handwashing,
Hand hygiene,
Nursing.
The articles that contained covered the problem and had clear methods were included. While 54 studies were found, only 11 were relevant to the hand hygiene and HAIs (Appendix B). Eight of them are examined below.
In the study by Boev and Xia (2015), the authors sought to find out the impact of the collaboration between nurses and physicians on hospital-acquired infections (HAIs). The study carried out a secondary analysis of 671 surveys of nurses’ perception data collected over a period of 4.5 years in 4 ICUs. Furthermore, patient outcome data were gathered on all 3610 patients that were discharged from the 4 ICUs over the course of the study period. The researchers used Collaboration and Satisfaction About Care Decisions (CSACD) to measure the collaboration between nurses and physicians. Demographics data on both the nurses and patients are provided in the study. The researchers found that the collaboration between nurses and physicians was significantly related to HAIs with the implication being that there is a potential to reduce HAIs with improved collaboration between the two. The examination of trends over time increased the internal validity of the research. There is a high external validity of the search because the collaboration between nurses and physicians can easily be applied in other healthcare settings.
In their study, Ceballos, Waterman, Hulett, and Makic (2013) carried out nurse-driven QI interventions to reduce HAIs in the newborn intensive care unit (NICU) over a two year period. The goal of the study was to reduce HAIs infection rate with a focus on CLASBI and Ventilator-associated pneumonia (VAP). Strategies to improve the CLASBI and VAP were deliberated twice monthly by a team comprised of a clinical nurse manager, charge nurses, medical director, respiratory therapy clinical supervisor, clinical nurse specialist, and infection-prevention nurse. Nurses were empowered to be leaders in the interventions. The subjects of the study were neonates with umbilical lines and venous catheters. Strict hand hygiene was among the strategies used to improve the conditions. Over the two year period, the study managed to attain significant and sustained decreases in CLASBI and VAP that resulted in noteworthy cost savings. There is high internal validity in the research with interventions clearly stipulated and outcomes quantified. The external validity is average given that the intervention requires a multidisciplinary team employing several strategies, meaning its application in other healthcare settings require time and planning.
Haque, Sartelli, McKimm, and Bakar (2018) was a non-analytic source that provided an overview of HAIs. The article was necessary for providing information on the background of the problem. It provided the statistics to justify why the problem of HAIs requires attention. The study examined 192 sources to provide relevant information about HAIs. The article describes the responsible causative organisms noting that 80%-87% of HAIs are caused by about 12-17 microorganisms. The article also describes the types of HAIs including surgical site infections (SSIs), CLASBIs, VAP, and Catheter-associated urinary tract infections (CAUTIs). The article, therefore, was useful in providing background information and statistics to justify the need for intervention.
Magill, et al. (2014) carried out a prevalence survey of HAIs in ten states to find out its prevalence in acute care hospitals. The states were geographically diverse. The researchers performed one-day surveys of inpatients that were selected in the participating hospitals while medical records were reviewed to determine the HAIs that were active during survey time. With 11, 282 patients spread across 183 hospitals being surveyed, 4% were found to have at least one HAI. The study also found that C. difficile was the most common pathogen and was associated with 61 HAIs. It was the conclusion of the article that on any one given day, about 1 of 25 patients in acute hospitals in the US has at least one HAI. The article was useful in providing background information on the prevalence of the problem. The research has high external validity given that the survey can easily be conducted in other hospitals.
A study by O’Donoghue, Suk-Hing Ng, and Boost (2016) examined the impact of multidimensional educational intervention compliance on hand hygiene among personnel in a radiography unit. Direct observation and questionnaires were used by the researchers to assess knowledge and attitudes towards the handwashing among the participants. The participants comprised of 17 nurses, 76 radiographers, and 9 healthcare assistants. The intervention was carried over a period of two months and it included talks on hand hygiene, visual aids, alcohol-based hand rubs (ABHR) mounted on walls, as well as personal ABHR bottles. The intervention resulted in an increased in compliance with hand hygiene from 28.9% to 51.4%. There was high internal and external validity of the approach because the intervention is applicable within and outside the setting.
Haverstick, et al. (2017) promoted hand hygiene among patients to reduce HAIs. The researchers provided patients in cardiothoracic postsurgical unit with hand sanitizer bottles while nurses and nurse technicians educated the patients on hand hygiene. The study aimed to provide the patients with the tools for protection against HAIs. All patients that were admitted to the unit were part of the experiment with a 6-question survey being administered the intervention. The survey was also administered one, two, and three months after the intervention. In 19 months after the intervention, there was a 70% reduction in Vancomycin-resistant Enterococcus (VRE). It was the conclusion of the researchers that hand hygiene can reduce HAIs.
Sickbert-Bennett, et al. (2016) examined the impact of high hand hygiene compliance on HAIs. The researchers examined a hand hygiene intervention in an 852-bed Noth Carolina Hospitals. Healthcare personnel was required to clean hands when they enter and leave patient rooms. The personnel was also asked to provide immediate feedback on one another. The study was carried over a period of 17 months. The results of the study showed that with every 10% improvement in hand hygiene, there was a 6% decrease in overall HAIs. The program can easily be replicated in other settings meaning there was high internal and external validity.
A study by Tschudin-Sutter et al. (2017) compared two hand hygiene techniques on their effectiveness. The two techniques were WHO’s 6-step guideline and a simplified 3-step procedure. The WHO’s six steps involve palm to palm rub, right palm over the left dorsum and vice versa, palm to palm with fingers interlocked, backs of fingers to opposing palms, and finally rubbing of fingertips and thumbs. As for the 3-step method, the first step is to cover all hands surfaces, the second step involves rotational rubbing of fingertips in the palms, and finally the third involves rubbing of both thumbs rotationally. Both studies show no significant difference in the bacterial count, however, the 3-step method received higher compliance.
Section D: Solution Description
Proposed Solution
This section describes handwashing as an intervention to reduce hospital acquired-infections at John Hopkins Hospital in Baltimore. Numerous studies have demonstrated that hand hygiene among healthcare workers and patients reduces HAIs rates. Hand hygiene interventions among healthcare workers have shown to reduce incidences of HAI infections (Chen, et al., 2011; Sickbert-Bennett, et al., 2016). In the study by Sickbert-Bennett, et al. (2016), high hand hygiene compliance among healthcare personnel produced a significant decrease in HAI incidences. Furthermore, according to studies by Haverstick et al. (2017) and Fox et al. (2015), handwashing compliance among patients contributed to significant decreases in HAIs infections. In their study, Fox et al. (2015) went further to show that when patients comply with hand hygiene requirements, it resulted in improved compliance to hand hygiene among nurses.
With the evidence described above, a handwashing intervention in Baltimore’s John Hopkins Hospital is expected to reduce HAIs infection rates. Specifically, the intervention will involve a three-step hand hygiene protocol sourced from a study by Tschudin-Sutter, et al. (2017). The authors simplified WHO’s hand hygiene guideline that is made up of six steps to come with a three-step procedure for healthcare personnel (Appendix F). The first step of the procedure is to cover all hands surfaces, the second step involves rotational rubbing of fingertips in the palms, and finally the third involves rubbing of both thumbs rotationally (Tschudin-Sutter et al., 2017). In the study, the researchers compared the simplified method with WHO’s six-step guideline and found out that the simpler method resulted in higher compliance. There was no significant difference between the two methods in terms of bacterial counts. Therefore, given the high compliance associated with the simpler method, the intervention in John Hopkins Hospital will utilize it.
The intervention is going to realistic in the John Hopkins hospital because it is a relatively simple procedure that does not require a lot of training for personnel and patients. Furthermore, hand washing is inexpensive and cannot overstretch the resources of the organization.
Organization Culture
The intervention is in-line with John Hopkins’ organizational culture of trust and cohesiveness, open communication, and an understanding of mission and goals. The handwashing intervention supports John Hopkins’ mission of setting excellence standard in research, clinical care, and education. The organization also has the capacity and resources to implement the intervention. As shown in organizational readiness assessment, there is support from top management as well as financial resources that can make EBP implementation possible. With the intervention being inexpensive, it is can be undertaken easily by the organization.
Expected Outcomes
It expected that after the implementation of the handwashing initiative among healthcare personnel and patients at the hospital will result in a significant decrease in HAIs. As shown by different studies, hand hygiene interventions are associated with a reduction in HAIs. This is the expected outcome of the intervention.
Methods to Achieve Outcomes
Having identified the intervention, target population, and the desired outcome, efforts will be directed towards implementation at the hospitals.
The intervention will be coordinated by a hospital employee with a senior clinical background, which is consistent with WHO guidelines.
The intervention will utilize the following resources: alcohol-based hand rub, one sink for every patient room as well as in bathrooms, and soap and towels at every sink.
Training will be provided to personnel while nurses will provide hand hygiene to patients according to the research by Haverstick et al. (2017).
Patients will be provided with hand sanitizer.
The hospital personnel will be expected to wash their hands before and after leaving a patient’s room.
The infection rates in the hospital will be evaluated before and after the intervention.
Potential barriers and limitations that need to be eliminated include forgetfulness, lack of knowledge of guidelines, insufficient time for hand cleaning, and prioritizing patient needs over hygiene (Mitchell, Boisvert, Wilson, & Hogan, 2017). Other barriers include the perception that hand hygiene is not needed if wearing gloves, distractions, and ineffective placement of sinks or dispensers.
Outcome Impact
The intervention will have a key impact on quality care improvement and professional expertise. As a result of the intervention, there will be reduced hospital stays, lower mortality, and reduced healthcare costs. This is because HAIs have been associated with negative outcomes in relation to mortality, healthcare costs, and length of hospital stays (Haverstick et al., 2017). Furthermore, from the intervention, healthcare personnel are bound to improve their expertise in hand hygiene.
Section E: Model of Change
Rogers' diffusion of innovation theory will be used in the implementation of the project. The model encompasses five stages at the individual level that include knowledge, persuasion, decision, implementation, and confirmation (Doyle, Garrett, & Currie, 2014). The model stipulates five categories of adopters of the hand hygiene intervention namely: innovators, early adopters, early majority, late majority, and finally laggards (Vedel et al., 2013). The model also identifies five key factors that affect the adoption of the intervention by healthcare workers. The notion behind the model is that over time, the handwashing intervention will become diffused among staff members and patients until a point of saturation is attained.
Stages
The knowledge stage will involve exposing the members of the intermediate step down unit to the handwashing intervention and its significance in reducing HAIs. Different strategies will be used depending on the category of the participants. Getting to the persuasion stage involves the participants having a perception of the intervention in terms of characteristics such as complexity, relative advantage, trialability, compatibility, and observability (Appendix C). To influence the persuasion, the concerns of participants will be addressed and literature analysis will be shared with them. In the decision stage, the participant must have encountered a situation that requires him or her to make a choice as to whether or not to be part of the intervention (Mohammadi, Poursaberi, & Salahshoo, 2018). Pilot studies will be conducted to influence the decision of participants (Doyle, Garrett, & Currie, 2014). For implementation stage to occur, the participant must decide that the intervention is the best option to address the existing issue. Continued support and education will be provided to help in adoption. The confirmation stage will be promoted through the sharing of success stories and carrying out a continuous evaluation (Doyle, Garrett, & Currie, 2014).
Categories
The first category of the model, the innovators, are enthusiastic about the intervention and as such, they will be interested in trying out the hand-washing intervention. Given their high level of interest in the idea, little effort will be required to appeal to them. However, as per the model, their percentage is small. Given their enthusiasm, this category of adopters will be recruited as educators of the intervention.
Early adopters make up the second category and as informed by Vedel, et al (2013), they adopt the intervention quickly and can serve as trendsetters. This category of individuals is highly influential in John Hopkins hospital and has the capacity to encourage the members of the Intermediate Step down Unit to adopt the intervention. They are bound to embrace the hand washing intervention and therefore will be integral in making it a success. Given their desire for change, information on implementation will be provided as they...