Evidence-based practice in nursing health care Example

University of St. Francis Master of Science in Nursing Program. N613: Evidence-Based Practice in Healthcare Grading and Development Guidelines for Evidence-Based Practice Project. The purpose of the Evidence-Based Practice (EBP) Project is to use the principles and context of EBP to evaluate a nursing practice, policy, or procedure in light of current evidence and make recommendations for change/improvement. Prepare the final project report using the following sections and guidelines. Use APA 7th edition format for all margins, citations, references, and headings as you prepare the paper.

In critically ill patients (p), how does hand washing before and after attending to a patient (I), compared to no hand washing (C) reduces the incidence of hospital-acquired infections (O) over a period of six months (T).

Introduction

Evidence based-evidence is a problem-solving approach to clinical practice that continuously incorporates the best evidence from well-researched studies, patients’ values and preferences, and clinician expertise in making decisions about patient care (Kim, et al, 2020). The evidence-based practice works hand in hand with clinical inquiries to raise questions and solutions to a certain practice element used in nursing practice. Clinical inquiry is the process in which a nurse or a healthcare professional raises questions about a certain practice whose efficacy is not yet proved by any study. Clinical inquiries are facilitated by the PICOT model which stands for problem or population, interventions, comparison, outcome, and time frame (Kim, et al, 2020). For example, the nurse inquired about the effect of hand hygiene when handling patients. The

PICOT model in this case; the problem is critically ill patients, interventions is hand washing or hand hygiene, comparison is between the patients who are attended after hand washing with those who do not. The outcome is a decrease in new cases of hospital-acquired infection, and the timeframe is within a specific period in which the research will be conducted. The clinical inquiries are proven through continuous research studies and observation during clinical work. When doing clinical inquiries, the care provider’s focus is on the quality indicators that can have the best interventions to prevent their occurrence as a quality improvement issue (Kim, et al, 2020). Hospital-acquired infections are the leading causes of prolonged hospitalization, hospital readmissions, and mortalities. These infections are caused by the care providers to the patients when handling patients. These infections can also be transmitted from one patient to the other through poor hand hygiene of the care provider. A research study will provide positive feedback regarding hand hygiene in the prevention of infection thus improving the quality of care and achieving patient satisfaction.

Rationale For Undertaking This Project

The reason for taking this project is due to the increase in the number of hospital-acquired infections due to poor hand hygiene when handling critical patients. In the United States of America, over 11,000 hospitalized patients in over 183 hospitals suffered from one HAI (Monegro, et al, 2020). Hospital-acquired infections HAI are nosocomially acquired illnesses whose incubating period is within the hospital stay. HAI includes urinary tract infections due to catheterization, ventilator-associated pneumonia, hospital-acquired pneumonia, surgical site infection, and clostridium difficile infections. Causes of HAI are septic procedures and poor hand hygiene. Septic procedures are such as septic surgical procedures, septic wound cleaning techniques, and septic catheterization techniques. Poor hand hygiene of care providers from one patient to the other causes more incidences of HAI (Monegro, et al, 2020). HAI leads to prolonged pain and suffering, prolonged hospital stay, increases the risks of patient readmission within 21 days after discharge, and increases the cost of hospital bills and resources. The onset of hospital-acquired infections is usually within 48 hours of hospital admission and it may present with fever, tenderness at the surgical site, abdominal pain, polyuria, dysuria, altered mental status, and rebound tenderness (Monegro, et al, 2020). Hand hygiene is the art of washing hands with running water and soap before and after attending to a patient, before handling personal items, and before feeding (Robles, A. 2020). In a hospital setup, hand washing reduces the transmission of infections. Maintaining hand hygiene decreases the excessive growth of microorganisms hence reducing infection risks, overall healthcare costs, readmissions, and length of hospital stay. According to Robles, A. (2020) hand washing is the most important element of infection control activities due to the growing burden of hospital-acquired infections.

A Targeted Literature Review on the Clinical Practice Problem of hand washing and hospital-acquired infections

Among the hospital-acquired infections, it is estimated that infections related to hand hygiene such as wound cleaning and catheterization have higher mortality compared to other HAIs. According to Monegro, et al, (2020) the most common cause of surgical site infections in post-cesarian section mothers is inadequate water supplies in the operating theatre, therefore, making the surgical procedure septic. The same applies to catheterization because the care provider does not have sterilized equipment. Critically ill patients have a low immunity compared to other groups of patients. Therefore, they are at a higher risk of contracting infections such as methicillin-resistant and vancomycin-resistant enterococcus which are colonized in the arms of healthcare providers (Monegro, et al, 2020). Care providers acquire these strains of bacteria through direct contact of other patients’ gowns, bedside furniture, and linen. These microorganisms are easily transferred from the arms of the care provider to the patient’s wound during cleaning and dressing. This causes slow wound healing, wound dehiscence, and finally sepsis. During catheterization, the resistant bacteria reside in the bladder causing chronic and frequent urinary tract infections.

HAIs are more prevalent in facilities whose hand hygiene practices remain irrelevant, unacceptably low, and rarely exceed 40% of the situations in which hand hygiene is recommended (Monegro, et al, 2020). In these healthcare organizations, their culture, behaviors, beliefs, and attitude towards hand hygiene are usually diminished because of working in an environment that does not have a good water supply or lack of knowledge on protocols and guidelines. The general environment is unhygienic causing HAIs thus prolonged hospitalization, increased cost of services, wastage of resources, and poor patient prognosis. Poor hand-washing techniques among the patient in the ward may also cause cross infections that eventually result in HAIs.

Current Practice Policies/ Procedures and Outcomes / Implications the Project Will Have or Impact at the Workplace

The study intends to improve compliance and bring change in the practice. Initiating practice policies in an organization is hectic for both the staff administration and the patients due to the fear of the unknown. Therefore, the organization’s management should train the staff about the importance of hand washing to improve the prognosis of the patient (Robles, A. 2020). Successful implementation of the transition of change by the organizational manager will have a positive impact due to strict compliance with the policies set aside. For instance, the installation of taps with running water and soap in all departments will lead to hand-washing compliance. Incorporation of the hand washing policy will result in all patients washing before leaving and entering the wards. Care providers are with hand sanitizers that kill the pathogens on the arms. The sanitizer is used before and after handling a patient. The organization should organize training programs for the staff and patients that will enable change in the perception of hand hygiene (Robles, A. 2020). The hospital should also have an infection control team that will disseminate evidence-based information in a comprehensible manner. Increasing the staff to fit the normal patient-nurse ratio will ensure compliance with hand hygiene because the nurse is assigned few patients to take care of during the shift. The outcome of the implication will be few cases of HAI mortalities, reduces pain and suffering, prolonged hospital stay, and facilitates quick recovery.

The PICOT Question

The picot question is a clinical inquiry that is related to a finding of if hand hygiene is effective and efficient in preventing the spread of hospital-acquired infections. Below, is a table that summarizes the elements of the PICOT statement. The PICOT model is then explained in the appendix section.

 

Table 1:

The PICOT components

P Problem and population Critically ill patients in a general ward or intensive care unit with hospital-acquired infections
I Interventions made to the critically ill patients in wards or ICU. Proper hand washing before and after handling a patient
C Comparison intervention No hand hygiene practices when handling a patient
O Outcome or result of the intervention Reduction in cases of HAI’s
T Timeframe of the intervention Six weeks

The PICOT question in full is, “In critically ill patients general ward or ICU for at least 48 hours (P), does the implementation of proper hand washing technique or hygiene (I) compared to usual care with no proper hand washing technique or hygiene (C) prevent the occurrence of hospital-acquired infections (O) within six weeks (T)?”

Evidence In Support Or Otherwise Of Proper Hand Washing Technique Or Hygiene In A General Ward Or ICU

Evidence is obtained in the current peer-reviewed articles or scholarly works and other reputable databases to yield good results. Evidence is searched after the PICOT questions formulation in the clinical inquiry process. During the research, keywords such as hand hygiene, hand washing, and hospital-acquired infections are entered into the research engine. The scholarly evident research engines are CINAL plus with full text, ProQuest, Embase, PubMed, and Cochrane Database of systemic reviews. The phrases are combined with the Boolean operator, AND, then entered into the database (Kim, et al, 2020). The study involved both the inclusion and exclusion criteria. The inclusion criteria involve the articles published within 5 years, studies that had interventions of hospital-acquired infections as an independent variable, the must either should have either randomized controlled trials, systemic reviews and meta-analysis, and or retrospective cohort studies. The evidence should be of high quality and value. The exclusion criteria include data that was published over 5 years, quantitative study methodology, and data with no hospital-acquired infections as an independent variable.

Studies Included in the Final Appraisal of the Evidence

The study produced more than 14,000 scholarly articles that were systemically taken through an exclusion process to arrive at the final number of 25 studies in the final appraisal of evidence. Other studies were duplicated and hence they were not fit for the study. Some documents did not meet the criteria and others did not pass the eligibility tests. Below is a list of four out of the 25 studies that passed the eligibility test.

Haverstick, et al, (2017) is a statistical analysis study assessing whether hand hygiene among patients would prevent hospital-acquired infections. This study provides level 11 for the hand washing interventions. The outcome of the study proved that patient hand hygiene reduced the spread of infections.

de Barra, et al, (2021), is a cohort interventional study that is giving insight into hand hygiene in the prevention of hospital-acquired infections. The study method was direct observation and questionnaires. The outcome of the study shows that hand washing is key in reducing the incidence of hospital-acquired infections. It recommends the convenient availability of sinks, SOAP, hand gel, hand towels, and hand sanitizers. This study provides a high level of evidence rated at level 11.

Kiersnowska, et al, (2019) is a randomized controlled trial that limits the sources of nosocomial clostridium difficile infection to hand hygiene. The author states that during the study, they found out that microbes reside in the hands of the care providers hence the higher prevalence of HIA’s in facilities that do not comply to hand washing. The author concludes that proper hand washing is the solution to the phenomenon. He recommends proper training of the healthcare facilities on proper techniques of hand washing to reduce mortalities associated with HAIs.

Kuti, B. P., et al, (2021) is a meta-analysis of data that determined the effectiveness of hand hygiene in preventing hospital-acquired infections among infants. The selection criteria involved mothers, caregivers, and pregnant women. The research methods used were retrospective controlled trials, quasi-experimental trials, and cross-over trials. The purpose of the study was due to the increased deaths in children due to HAIs that were associated with a lack of proper hand hygiene. The author concludes that hand washing was proven to be effective in preventing hospital-acquired infections.

References

de Barra, M., Gon, G., Woodd, S., Graham, W. J., de Bruin, M., Kahabuka, C., … & Penn-Kekana, L. (2021). Understanding infection prevention behavior in maternity wards: A mixed-methods analysis of hand hygiene in Zanzibar. Social Science & Medicine272, 113543.

https://doi.org/10.1016/j.socscimed.2020.113543

Haverstick, S., Goodrich, C., Freeman, R., James, S., Kullar, R., & Ahrens, M. (2017). Patients’ hand washing and reducing hospital-acquired infection. Critical care nurse37(3), e1-e8.

https://doi.org/10.4037/ccn2017694

Kiersnowska, Z. M., Lemiech-Mirowska, E., Michałkiewicz, M., & Marczak, M. Hand hygiene as the basic method of reducing Clostridium difficile infections (CDI) in a hospital environment. Annals of Agricultural and Environmental Medicine.

https://doi.org/10.26444/aaem/131121

Kim, M., Mallory, C., & Valerio, T. (2020). Statistics for evidence-based practice in nursing. Jones & Bartlett Publishers.

Kuti, B. P., Ogunlesi, T. A., Oduwole, O., Oringanje, C., Udoh, E. E., & Meremikwu, M. M. (2021). Hand hygiene for the prevention of infections in neonates. Cochrane Database of Systematic Reviews, (1).

https://doi.org/10.1002/14651858.CD013326.pub2

Monegro, A. F., Muppidi, V., & Regunath, H. (2020). Hospital acquired infections. StatPearls [Internet].

Robles, A. (2020). Handwashing in healthcare settings in low-and middle-income countries: Literature review on handwashing in maternal care.

http://urn.fi/URN:NBN:fi:amk-2020120726571