Importance of Hand Decontamination - Essay Example

Evidence Based Research Contents 0. Introduction 2.0. Process 3.0. Evidence-based research 4.0. Literature search 5.0. Methods 6.0. Literaturereview 7.0. Evidence 7.1. Evidence from CDC 7.2. Observations 7.3. RCN guideline 7.4. Enquiry from Staff 8.0 Explanation 9.0 Problems 10.0 Conclusion 11.0 Reference List 12.0 Appendix 1.0. Introduction: Evidence-based research and research-guided practice in medicine, healthcare, and nursing influence the present-day healthcare policy to the greatest extent. These researches are used increasingly to evaluate the effectiveness of care, and evidence-based researches have significant impact on decision-making process in nursing care. This is application of explicit and judicious use of latest best evidence about the care of the individual patient. Healthcare, no longer, is opinion based, rather it is increasingly using science, research, and evidence to guide practice. Like any other field, the principles of evidence-based research can be used to judge the appropriateness of care. The aim of this assignment is to demonstrate my ability to collect and analyse evidences on a selected practice-based care intervention. I have chosen hand washing as the area of practice. I intend to discuss the process of evidence collection. In relation to that, my aim is also to discuss the strength and limitation of accessing the evidence. In this way, this assignment will help me to develop knowledge and skills of information warehousing and evidence analysis in relation to my day-to-day practice. 2.0. Process: I have selected hand decontamination as my area of study. Hand decontamination is an area that is a simple precautionary measure, and it is a well-known fact that nurses' hand-washing between seeing each patient would control 80% of the hospital-acquired infections, namely, dangerous methicillin-resistant Staphylococcus aureus (Royal College of Nursing, 2005). It is also established that hand washing is far more important than cleaner wards to prevent infections. Since nurses are primarily attached to the patients in a ward setting, nurses' hand washing may play a great role in preventing contamination and hence spread of infection (The Infection Control Nurses Association (ICNA), 2003). 3.0. Evidence-Based Research: When I was first placed in the medical ward for my practice placement, the senior nurse in the ward highlighted the hand washing practice and demonstrated techniques of them. I had an idea that hand washing is important but needs not be ritualistic. I started understanding that my knowledge on hand washing needs is poor and superficial. I made it a point to develop my knowledge in this area to improve the standards of my practice and enhance my care for the patient. I decided to undertake an evidence-based research on hand washing by the nurses in clinical areas. Current literature is not voluminous in this area. 4.0. Literature Search: I undertook an electronic database research with the key words, hand washing, hand decontamination, nurses, washing practice, washing beliefs, sanitary habits in different databases and resources including Cinahl, Cochrane, Medline, British Medical Journal, CEBM, NMAP, and Highwire Press. This resulted in a total of 234 articles. Then to narrow the focus, another search was undertaken with all key words, evidence-based research, hand washing, and nursing in three different instances. This resulted in 32 articles. In these 32 articles, all these key words were utilized to undertake a final search leading to a total of 7 articles. 5.0. Methods: This has been done to undertake an evidence-based research and to find evidence for the same. Research is basically a systemic enquiry, which is reported in a form that allows the research methods and outcomes to be accessible to others so that people can implement change in practice with dissemination of the inference. This can be done in two ways, by seeking solutions to meaningful questions and nonmeaningful questions. Nonmeaningful questions are not answerable by enquiry alone (Walsh, M. and Wigens, L., 2003). As a result, positivist method deals with positive facts and observable phenomenon. This is best suitable for scientific researches where scientific observations or findings are recorded. After analysis of these findings, one may not only describe, but also predict and explain the findings on the basis of those analyses. These findings can then be classified and inferred to form descriptive laws that may serve as new findings that can be generalized and propagated (Meyer, J., 2000). It draws on measurable evidence, so best suitable for quantitative researches. The other method is naturalistic or phenomenalistic. This is a narrative and qualitative methodology that relies on subjective content implying the researcher's intention. The outcomes are descriptions (Mann, C.J., 2003). In our study, thus, the positivist approach is used to collect data via observation and review, to classify types of incidents, to produce analyses, and to make recommendations based on analysis. In this study, it required analysis of the findings and reviews in depth to be able to draw conclusions about the causal factors about the study question in an essentially qualitative way. As a result, the data collection tool directly points to development of appropriate questionnaire that carefully takes care of the form and the content applicable to the study population interviewed (Campbell, S.M., Braspenning, J., Hutchinson, A., and Marshall, M., 2002). In this study, the data collection was simple. I just studied the literature on hand washing, hand-washing techniques, and observed the practice of the senior nurses in the clinical settings and recorded those to see whether evidence-based research is being utilised in the practice setting. 6.0. Literature Review: The literature review revealed hand washing in the healthcare setting is recognized as the single most important procedure for prevention of infection. This has been an emerging concept to lead to guidelines to be followed by the nurses in the clinical setting. Hand hygiene is a well recognised integral part of the quality patient care. The question arises whether the prevalent practice is good and sufficient enough or whether new developments as emerge from review of recent literature and research need to be incorporated in practice (Pratt, R.J., Pellowe, C., Loveday, H.P., Robinson, N., Smith, G.W., and The Epic Guideline Development Team, 2001). 7.0. Evidence: Almost all the literatures consider the knowledge about the skin bacterial flora important for understanding the different approaches to hand hygiene. Two kinds of bacteria stay commensally in the hand skin, transient and resident. Social hand hygiene by simply washing the hands would remove the transient or superficial bacterial flora, such as, Staphylococcus aureus that has long been considered as healthcare-associated bacterial contamination. The deeper layer of skin, however, harbours bacteria that are not amenable to simple washing. The literature says contamination with such bacteria may be life threatening and has been an acclaimed association with heart valve or orthopaedic infections acquired from hospital setting. 7.1. Evidence from CDC: Since this observational study is designed for enhancement of knowledge and care, no interventions are intended out of this except my personal practice methods. Since preexisting databases provide excellent and convenient source of data, the databases that I mentioned would serve as an extensive pool of information. I have decided to study the literature that I have finalised and then compare those with my actual experience and observation in the ward (Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force Centers for Disease Control and Prevention (CDC), 2002). 7.2. Observations: With due permission from authority and the staff nurse, I decided to make and record observations in the ward about how the staff goes about the hand washing in the clinical setting. I have observed that the staff before and after attending a patient goes to the wash basin, takes out her watch and ring, and then thoroughly rinses her hands with water right from the elbows to the fingertips. She is repeatedly washing these areas with soap and water taking special care not to avoid any areas. The ward had adequate facilities in all patient areas and treatment rooms. I observed that the wash basins in these areas are special in that they have elbow lever-operated mixer taps and are provided with liquid soap dispensers, paper hand towels, and foot-operated waste basins. In some cases there were alcohol hand rubs and gels available along with that. I had observed in some cases, when workload is high and less time is available for hand wash, the staff is using alcohol rub instead of soap wash (Pellowe, C., Pratt, R., Loveday, H., Harper, P., Robinson, N., and Jones, S., 2004). 7.3. RCN Guidelines: The RCN guidelines for hand hygiene clearly state that the hands should be decontaminated with correct techniques by washing with a soap or using alcohol solution, and this procedure needs to be stringent before direct contact with the patient or after any activity or contact with the patient including after removal of the gloves. Although alcohol is widely used as a rub in the clinical setting, soap and water wash is ideal, and after the wash, the hands should be dried thoroughly. The hands of the healthcare professionals ideally should have short nails, free of polish and clean. It has been shown that wrist watches, jewellery, rings, or rings with stones carry bacteria potentially, hence they should not be worn. While artificial nails are potentially dangerous, any cuts or abrasions must be covered with water-proof dressings for both patient and personal safety (Royal College of Nursing 2005). 7.4. Enquiry from Staff: Observing all ethical requirements, I enquired with the staff nurse why she uses alcohol-based hand rubs in some occasions. The literature states that alcohol-based hand rubs with added emollients are very effective antimicrobial agents when applied to hands for a minimum of 15 seconds using an adequate volume to completely wet the hands. My observations state that while using alcohol to wash hands, she is keeping her hands up and free in air with elbows flexed for certain period of time. This observation tallied with the necessity of drying the hands adequately by evaporation. Evidence from literature suggests that alcohol-based rubs are superior hand hygiene product for almost every situation. They are strongly recommended for social and antiseptic hand hygiene in all patient care areas, but they must always be used on visibly clean hands (Larson, E.L., Aiello, A.E., and Bastyr, J., et al., 2001). I discussed this issue with the staff and desired to know when to use alcohol-based hand wash in order to find evidence whether clinical practice is in conformity with research findings from the literature. I observed her to wash her hands with alcohol-based rubs in a patient while starting an intravenous line and while inserting a Foley catheter. Indeed, it has been recommended by the guidelines that it is mandatory before performing invasive procedures as a part of an antiseptic technique. Although my clinical placement was in the general medical ward, as per guidelines, hand washing by this technique, as expected, must be more stringent in critical care units, burn units, or surgical units. In these situations, a high bacterial load is expected to exist, and fear of contamination or actual contamination can only be averted by stringent and strict hand wash protocols since chances of contact with heavily infective material are very high in such situations (Widmer, A.F., 2000). The collection of information or access to data was easy by the technique that I followed by gradually narrowing the search, but it should be mentioned that apart from the RCN guidelines, most literature discussed findings on healthcare workers in general. Only two literatures were available specifically for nurses in the general medical setting. Another limitation was that corroboration of the evidence in the clinical setting by observing the actual observation of the hand washing practice was very difficult since the environment in the ward is extremely busy, and the workload seemed to be inordinate in comparison to the number of staff (Krankenpfl Soins Infirm, 2000). Although the curriculum covers the theoretical aspects of hand decontamination adequately, my observation suggests that promotion of hand hygiene is lacking in the ward environment. Since catastrophic events are less visible in a busy clinical setting, most nurses tend to follow their own culture and beliefs in hand washing practices. It should be remembered that effects of improper hand washing may be evident even after the patient is discharged from the hospital or it may endanger the professional safety of the nurses by predisposing to a communicable disease in the nurses themselves. There should be better ways of transmission of evidence from researches to the profession so that evidence can be transformed into a updated practice protocol (National Institute of Clinical Excellence, 2001). To conclude, this assignment has taught me the importance of hand washing in the clinical setting, especially as applicable to nursing practice. Application of research methods and literature review establishes the theoretical background of commensal flora on the hands of the nurses, and the effects of contamination may be detrimental for both the nurses and the patients. Even apparently clean hands can be contaminated, hence warm soap water wash before and after any patient contact is mandatory per guidelines, and despite the fact that there are adequate facilities of hand wash in the ward, the rigor of techniques are not always followed. Alcohol-based hand washing is also recommended in settings of invasive nursing care because that can turn out to be life threatening, and to be an effective practice, dissemination of education and practice with promotion is mandatory in the clinical setting. Reference List Campbell, S.M., Braspenning, J., Hutchinson, A., and Marshall, M., (2002). Research Methods Used In Developing And Applying Quality Indicators In Primary Care. Quality and Safety in Health Care; 11: 358. Department of Health, (2004). Towards Cleaner Hospitals And Lower Rates Of Infection. A Summary Of Action. London: Department of Health.. Available to download from www.dh.gov.uk. Krankenpfl Soins Infirm, (2000). Modification of a nursing practice based on evidence. Hygienic washing and disinfection of hands ; 93(4): 79. Larson, E.L., Aiello, A.E., and Bastyr, J., et al., (2001). Assessment Of Two Hand Hygiene Regimens For Intensive Care Unit Personnel. Critical Care Medicine; 29:944-51 Mann, C.J., (2003). Observational Research Methods. Research Design II: Cohort, Cross Sectional, And Case-Control Studies. Emergency Medical Journal; 20: 54. Meyer, J., (2000). Qualitative Research In Health Care: Using Qualitative Methods In Health Related Action Research. British Medical Journal; 320: 178. National Institute of Clinical Excellence, (2001). Standard Principles For Preventing Hospital Acquired Infections. London. NICE. Pellowe, C., Pratt, R., Loveday, H., Harper, P., Robinson, N., and Jones, S., (2004). The Epic Project: Updating The Evidence-Base For National Evidence-Based Guidelines For Preventing Healthcare-Associated Infections In NHS Hospitals In England: A Report With Recommendations. British Journal of Infection Control, 15(6), Dec., pp.10-16. Pittet, D., Hugonnet, S., Harbarth, S., Mourouga, P., Sauvan, V., and Touveneau, S., (2000). Effectiveness Of A Hospital-Wide Programme To Improve Compliance With Hand Hygiene. Lancet; 356:1307-12. Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force Centers for Disease Control and Prevention (CDC), (2002). Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control. MMWR 2002; 51: (No. RR-16). Pratt, R.J., Pellowe, C., Loveday, H.P., Robinson, N., Smith, G.W., and The Epic Guideline Development Team, (2001). The Epic Project: Developing National Evidence-Based Guidelines For Preventing Health-Care Associated Infections, Phase 1: Guidelines For Preventing Hospital Acquired Infections. Journal of Hospital Infections; 47 (Suppl): S1-S82. Royal College of Nursing (2005). Good Practice in Infection Prevention and Control: Guidance for Nursing Staff. London: RCN. Publication Code: 002 741 Royal College of Nursing (2005). Methicillin-Resistant Staphylococcus Aureus (MRSA). Guidance For Nursing Staff. London: RCN. Publication code: 002 740. Tenorio, A.R., Badri, S.M., and Sahgal, N.B., (2001). Effectiveness Of Gloves In The Prevention Of Hand Carriage Of Vancomycin-Resistant Enterococcus Species By Health Care Workers After Patient Care. Clinical Infectious Diseases; 32:826-9. The Infection Control Nurses Association (ICNA), (2003). Guidelines for Hand Hygiene. 2003. ICNA in collaboration with DEB, Bathgate, London. Walsh, M. and Wigens, L., (2003). Introduction to research, Foundations in Nursing and Health Care. Widmer, A.F., (2000). Replace Hand Washing With Use Of A Waterless Alcohol Hand Rub Clinical Infectious Disease; 31: 136-43. Appendix Evidences 7.5. Evidence from CDC I. Indications for handwashing and hand antisepsis A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water. B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items I C-J. Alternatively, wash hands with an antimicrobial soap and water in all Clinical Situations described in items I C-J. C. Decontaminate hands before having direct contact with patients. D. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter. E. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure. F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a Pulse or blood pressure, and lifting a patient). G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care. I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. J. Decontaminate hands after removing gloves. K. Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water. L. Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of HCWs they are not a substitute for using an alcohol-based hand rub or antimicrobial soap. M. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if exposure to Bacillus anthracis suspected or proven. The physical action of washing and rinsing bands under such circumstances is recommended because alcohols, chlorhexidine iodophors, and other antiseptic agents have poor activity against spores. N. No recommendation can be made regarding the routine use of nonalcohol-based hand rubs for hand hygiene in health-care settings. Unresolved issue. II. Hand-hygiene technique A. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and Fingers, until hands are dry. Follow the manufacturer's recommendations regarding the volume of product to use. B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis. C. Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing hands with a nonantimicrobial soap and water. When bar soap is used, soap racks that facilitate drainage and small bars of soap should be used. D. Multiple-use cloth towels of the hanging or roll type are not recommended for use in health-care settings. III. Surgical hand antisepsis A. Remove rings, watches, and bracelets before beginning the surgical hand scrub. B. Remove debris from underneath fingernails using a nail cleaner tinder running water. C. Surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand rub with persistent activity is recommended before donning sterile gloves when performing surgical procedures. D. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually 2-6 minutes. Long scrub times (e.g., 10 minutes) are not necessary. E. When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturer's instructions. Before applying the alcohol solution, prewash hands and forearms with a non-antimicrobial soap and dry hands and forearms completely. After application of the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves. IV. Selection of hand-hygiene agents A. Provide personnel with efficacious hand-hygiene products that have low irritancy potential, particularly when these products are used multiple times per shift. This recommendation applies to products used for hand antisepsis before and after patient care in clinical areas and to products used for surgical hand antisepsis by surgical personnel. B. To maximize acceptance of hand-hygiene products by HCWs, solicit input from these employees regarding the feel, fragrance, and skin tolerance of any products under consideration. The cost of hand-hygiene products should not be the primary factor influencing product selection. C. When selecting non-antimicrobial soaps, antimicrobial soaps, or alcohol-based hand rubs, solicit information from manufacturers regarding any known interactions between products used to clean hands, skin care products, and the types of gloves used in the institution. D. Before making purchasing decisions, evaluate the dispenser systems of various product manufacturers or distributors to ensure that dispensers function adequately and deliver an appropriate Volume of product. E. Do not add soap to a partially empty soap dispenser. This practice of "topping off" dispensers can lead to bacterial contamination of soap. V. Skin care A. Provide HCWs with hand lotions or creams to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or hand-washing. B. Solicit information from manufacturers regarding any effects that hand lotions, creams, or alcohol-based hand antiseptics may have on the persistent effects of antimicrobial soaps being used in the institution. VI. Other Aspects of Hand Hygiene A. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms). B. Keep natural nails tips less than -inch long. C. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur. D. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients. E. Change gloves during patient care if moving from a contaminated body site to a clean body site. F. No recommendation can be made regarding wearing rings in health-care settings. Unresolved issue. VII. Health-care worker educational and motivational programs A. As part of an overall program to improve hand-hygiene practices of HCWs, educate personnel regarding the types of patient-care activities that can result in hand contamination and the advantages and disadvantages of various methods used to clean their hands. B. Monitor HCWs' adherence with recommended hand-hygiene practices and provide personnel with information regarding their performance. C. Encourage patients and their families to remind HCWs to decontaminate their hands. VIII. Administrative measures A. Make improved hand-hygiene adherence an Institutional priority and provide appropriate administrative support and financial resources. B. Implement a multidisciplinary program designed to improve adherence of health personnel to recommended hand-hygiene practices. C. As part of a multidisciplinary program to improve hand-hygiene adherence, provide HCWs with a readily accessible alcohol-based hand-rub product. D. To improve hand-hygiene adherence among personnel who work in areas in which high workloads and high intensity of patient care are anticipated, make an alcohol-based hand rub available at the entrance to the patient's room or at the bedside, in other convenient locations, and in individual pocket-sized containers to be carried by HCWs. E. Store supplies of alcohol-based hand rubs in cabinets or areas approved for flammable materials. Performance Indicators The following performance indicators are recommended for measuring improvements in HCWs' hand-hygiene adherence: A. Periodically monitor and record adherence as the number of hand-hygiene episodes performed by personnel/number of hand-hygiene opportunities, by ward or by service. Provide feedback to personnel regarding their performance. B. Monitor the Volume of alcohol-based hand rub (or detergent used for handwashing or hand antisepsis) used per 1,000 patient-days. C. Monitor adherence to policies dealing with wearing of artificial nails. D. When Outbreaks of infection Occur, assess the adequacy of health-care worker hand hygiene. 7.6. Observations As a result, this observational study is not an experiment; whereas, this is just finding associated with incident. Despite the external variables being difficult to be controlled, if a clear and significant association is found between hand washing practices and incidence of infection in the ward setting, then a judgment may be made about the casual link. These judgments would at least permit me to answer and learn the fundamental questions regarding hand washing practices. Staphylococci and other commensal organisms may easily contaminate the patient's environment, such as, bed linens, clothing, and furniture from where they may transfer to the nurses' hands. Thus, quality of care may be indicated by the incidence of hospital-acquired infections. The nurse needs to approach this issue by being responsive to the patient's needs in the context of reduction of risks of infection that might compromise the patient's health (Tenorio, A.R., Badri, S.M., and Sahgal, N.B., 2001). In reality, there have been consistent reports of poor compliance of the healthcare professionals with the accepted standards of hand hygiene, and consequently, poor hand hygiene may result in a possible adverse event for the patient. It is not the culture in practice always that is responsible for such adverse events; sometimes, overcrowding, and understaffing is responsible for such events (Pittet, D., Hugonnet, S., Harbarth, S., Mourouga, P., Sauvan, V., and Touveneau, S., 2000). The validity of my proposition holds good since there is ample evidence that presence of nosocomial pathogens in the hands of healthcare workers leads to contamination. This contamination may happen during contact with a patient's wound, mucous secretions, intact skin, and even contaminated objects within the patient's environment. The hands of nurses may become contaminated even during clean activities like taking a pulse, repositioning a patient, and even during touching the patient. It is also mentioned in the literature that certain patient groups are more prone to carry Staphylococcus aureus on the intact skin. 7.7. RCN guideline Despite the fact that there is a guideline in place to improve hand washing practices of the healthcare professionals, it seems from the current research findings that healthcare professionals fail to understand the importance of hand washing. There has been well-laid guidelines for the healthcare professionals to follow from different authorities, and it is mandatory that nurses hands need to be decontaminated before every patient contact. There is evidence that even when taught the theoretical basis of hand decontamination, the healthcare professionals fail to decontaminate hands in compliance with practice guidelines. 7.8. Enquiry from Staff Hand washing with plain soap and warm water is recommended when hands are visibly contaminated with dirt, soil, or organic material, that is, hands should be always washed when visibly contaminated. Hands should be decontaminated at the beginning and end of the work shift and before and after each patient contact. It should not be spared even before and after wearing gloves while delivering patient care. This also includes instances when the nurse handles soiled equipment, materials, or environment. This is mandatory before preparing or handling food. The nurse must not forget to wash hands after personal bodily functions, such as, using lavatory or blowing nose (Department of Health, 2004). Read More