Discuss about the Applied Research for Evidence Based Practice.
The assignment deals with the infection prevention control practice. The nursing issue dealt in this study include “Use of best hand hygiene practice to prevent infection”. The essay provides brief background of the issue. It explains the search strategy used for selecting the articles for the study. The level of evidence for each of the article is identified. Further, for each of the articles the practical recommendations in the health care setting are discussed and it is determined in the essay if the recommendations are applicable in the health care setting of New Zealand. By effectively communicating the findings of the study it is possible to directly influence the changing behaviours of the health care workers and to promote improved hand hygiene in New Zealand.
The demand for Evidence Based Practice (EBP) is accelerating over time. The purpose of this study is to develop research skills and implement EBP. EBP is the process of using “current best evidence” explicitly and judiciously to make decisions about individual patient care (LoBiondo-Wood et al., 2013). The purpose of EBP is to integrate clinical opinion into practice to provide high quality of services taking into account the needs, values, choices and interests of the patients (Schneider & Whitehead, 2013). Integrating best evidence into the clinical expertise will assist in using modern day practices to deliver client focused care.
Hand hygiene practice is crucial for the heath care workers. They frequently are exposed to opportunistic pathogens such as Clostridium difficle, Candida spp. (that can survive for as long as 150 hours) which cause severe nosocomial infections (Guilhermetti et al., 2010). Presence of multi-drug resistant pathogens (S. Aureus) increases the rate of nosocomial infections and complexity of treatment. Therefore, Nurses and doctors must strictly adhere to the hand hygiene guidelines for preventing the outbreak of infectitious diseases as it is recognised to be the “most effective method” (Guilhermetti et al., 2010). Inaccessibility of the hand hygiene products or skin irritations acts as a barrier to maintain hand hygiene. The key problem is the use of effective hand hygiene method to prevent the infection as well as enhance the adherence to “hand-hygiene practice recommendations”. Therefore, the study aims to investigate how does hand?washing compare with use of gel preparation?
The articles were selected with the objective of identifying published randomised journals and other research papers related to hand hygiene in the health care setting using gel based preparation. For the purpose of literature review the standard search strategy is used that involves use of five databases CINAHL, Cochrane Library, Google Scholar, Medline, and PubMed. Focus was mainly on the articles that gave primary data from randomised control trials and few systematic reviews were include to identify any additional information on the topic. The inclusion criteria was to consider articles published between 2006-2016 that describes prevention of infection while comparing hand washing to the gel based preparations. Articles that are published in English are selected for the study. Articles that were not meeting the inclusion criteria were excluded. Initially the articles were screened on the basis of the abstracts followed by full text review. The search terms used for article selection are:
“hand hygiene”, “hand disinfection”, “hand washing”, “alcohol-based hand gels”, “nosocomial infections”, “health care associated infections”, “efficacy of hand gel in critical care unit”, “effectiveness of hand washing in surgical hand preparation”, “efficacy of soap and water in hand disinfection”, “compliance prevention”, “patient safety”
EBP is ranked by the way the evidence was collected. The example of a hierarchy system is given below: (Polit & Beck, 2008)
Level 1: Systematic reviews of randomized and non-randomized clinical trials
Level 2: Single randomized and non-randomized clinical trials
Level 3: Systematic review of correlational and observational studies
Level 4 Single correlational and observational studies
Level 5: Systematic review of descriptive, qualitative, and physiologic studies
Level 6: Single descriptive, qualitative, and physiologic studies
Level 7: Opinions from authorities, and expert committees
A total of 13 articles were selected that provides evidence supporting the clinical question related to hang hygiene.
The first article, a systematic review,( in level 1) by Fung & Cairncross, (2006) provided an evidence of effectiveness of hand washing in preventing the transmission of severe acute respiratory syndrome. The study provided no detectable difference in effectiveness of soap and gel based hand rub. Ejemot?Nwadiaro et al., (2008) in level 1 evaluated that the efficacy of hand washing intervention on preventing diarrhoea. This study described that hand washing practice is effective in reducing episodes of diarrhoea by about one-third. Moreover, this system is effective in low income areas. However, significant reduction is comparable to the effect of providing clean water in low-income areas. Traore et al., (2007) has conducted a prospective intervention study (in level 2) to assess the efficacy of the gel formulation in increasing hand hygiene compliance during patient care. The quantitative study compare between liquid and gel based formulation in regards to acceptability and skin tolerance among users. The findings showed that the hand washing with gel-based formulation was more effective than liquid formulations. It also demonstrated that easy accessibility to “alcohol-based gel formulation” increased the adherence to hand hygiene guidelines. The gel-based formulation was better accepted and had better skin condition then the other counterpart. However, it did not investigate the difference in infection rates using these formulations. These results have produced valuable information that gel based product was effective in maintaining nurses’ compliance to the hand hygiene. The prospective controlled, cross-over trial (level 2) by Rupp et al., (2008) conducted in two medical-surgical ICUs also monitored the efficacy of alcohol-based hand gel in preventing nosocomial infections and hand hygiene adherence. The results of this quantitative study showed a significant improvement in the rate of hand hygiene adherence (from 38% to 68% in both ICUs) among all the health care workers. This gel lowered the number of absolute microbes on hands. Increased number of microbes in some cases of culture study was attributed to inaccessibility to gel and longer fingernails. However, the study could not better delineate the relationship between the hand hygiene and the nosocomial infections. Guilhermetti et al., (2010) conducted a quantitative study (level 2) to investigate the efficacy of twelve of alcohol-based hand gels produced in Brazil. The gels were compared to the reference solution (2-propanol) from the EN 1500. In the study, 10 out of 12 gels were approved within application time of 60s. The study results recommend the use of alcohol based gel in the hospital settings. Among these gels, Sterillium Gel was best, with the capacity to reduce 90% of the E.coli populations within 60s more than the reference alcohol. Three of the gels were as 70% effective in removing S. Aureus and Candida albicans from highly contaminated hands. The single observational study in level 4 by Kampf, & Hollingsworth (2008) also evaluated the bactericidal activity of sterilium (hand gel) as well as the time of its action on different microorganisms. The results showed that the gel has broad spectrum antibacterial activity and works within 15 seconds of applications. It is active against most common species under the category of causative agents of nosocomial infections as well as other emerging pathogens.
The randomised trial in level 2 by Liu et al., (2010) demonstrated that liquid soap treatment and water rinse was effective hand hygiene practice in reducing the “genomic copies of Norwalk virus” on human finger pads. The study also demonstrated that alcohol based sanitizers were relatively ineffective in controlling the pathogen transmission particularly virus. The cluster-randomised, crossover trial in level 2 by Nthumba et al., (2010) compared the efficacy of the hand washing with “soap and water” versus “alcohol based rub” for surgery preparation. The study described the feasibility and affordability of alcohol-based hand rubs for hand preparation before surgery. It is effective in preventing surgical site infections in comparison to hand washing with soap and water in clinical settings without continuous supply of clean water. However, the study did not show any significant statistical difference in rate of infection in soap versus alcohol based rub hand washing. Gerding et al., (2008) in the single descriptive study (level 6) have described that hand wash using soap and water is effective in preventing and controlling the Clostridium difficile infection (CDI). It has also described that hand hygiene with gel based preparation was ineffective in controlling CDI. The randomise trial by Sasahara et al., (2014) in level 2 determined the appropriate procedure of hand hygiene for controlling nosocomial Bacillus cereus. The results demonstrated that the soap washing procedures were highly effective as it decreased the number of B. Cereus spores b y more than 2 log10. The other procedures such as use of alcohol based gel, liquid, were not as effective as soap and water treatment. Similar study was conducted by Ji & Jeong, (2013) which is also under level 2 demonstrated that the efficacy of different types of alcohol gel in eliminating pathogens according to their amount and drying time. The results demonstrated that only alcohol gel hand hygiene with adequate amount of (2mL) and complete dry (30 seconds rubbing followed by 2 min air-dry), were effective in disinfecting microorganisms and it was also considered satisfactory by the “U.S. FDA-TFM efficacy requirements for antiseptic hand hygiene products”. Therefore the study recommends the use of this type of gels in health care setting. Erasmus et al., (2010) conducted a systematic review (level 5) on observed or self reported hand hygiene compliance rates in hospitals. The results indicated that the compliance rates were higher when nurses performed dirty tasks and were given greater access to the gel based preparation. The review by Kampf & Loeffler, (2007) in level 7 on hand hygiene practices described that the low compliance rate of hand hygiene among the heath care workers is due to hand washing. Use of soap and water often causes skin irritations and dermatitis. As per the review, hand washing is less effective when compared to the gel based preparations and other alcohol based hand rubs for disinfecting hands. Gel based and other alcohol based hand hygiene is useful to prevent irritant contact dermatitis.
Thus, the literature indicates that both hand washing and use of gel-based preparation were effective in prevention of infections in healthcare setting. The studies of (Traore et al., 2007; Rupp et al., 2008 and Guilhermetti et al., 2010, Ji & Jeong, 2013 in the level of evidence 2 and Kampf, & Hollingsworth 2008 in level 4) have been more specific in recommending the use of gel based preparations for maintaining hand hygiene in clinical settings for their efficacy in controlling pathogen transmission. According to Polit & Beck, (2008) the articles belonging to level 1 and 2 are of best quality and should be given first preference as these studies does not contain major flaws and conclusions are well drawn. Therefore, gel based preparation can be recommended for use in New Zealand’s health care setting. However, the study of Fung & Cairncross, (2006) in level 1 on hierarchical system of evidence cannot be recommended as the quality was low and the results were not conclusive. Hand washing can be recommended in New Zealand on the other hand based on Ejemot?Nwadiaro et al., (2008) also in level 1. The information from this study suggests strict adherence to hand washing practices for preventing infections which will also be applicable in New Zealand’s health care setting. The study by Liu et al., (2010) and Sasahara et al., (2014) both in level 2 was contradictory to these studies as it demonstrated that hand washing soap and water is more effective in pathogen control. It showed that the hand sanitizers or alcohol based gel rub were not effective in controlling viral population on the human fingers. On the other hand, Nthumba et al., (2010) in level 2 recommends hand washing with soap and water to be more effective in disinfecting viruses. Gerding et al., (2008) in level 6 recommends hand washing with soap and water to be effective in disinfection of CDI. In addition, according to Kampf & Loeffler, (2007) hand washing is associated with skin irritations and decrease in the rate of compliance to hand hygiene practice but it cannot be considered a reliable information as according to Polit & Beck, (2008) the level of evidence is low for this study.
In conclusion, hand wash using both the soap and water as well as gel based preparation is recommended for New Zealand’s health care setting. It was found from the critical review of 13 articles that both hand wash and gel based preparation are equally effective in preventing nosocomial infections. Both have the efficacy to remove viruses as well as spores. However, I would personally give a special preference to gel based hand hygiene preparation. In case of gel base preparation Sterillium is particularly recommended to be used as two high level of evidence has been found that have proved its effectiveness against broad-spectrum of bacterial activity and acts in a short span of time that is 15 secs. This short time of application and high level of efficacy of the gel if used in hospital setting would increase the compliance and adherence to hand hygiene guidelines and prevent major outbreak of infectitious diseases. Moreover, there is more evidence on recommendations for gel based hand hygiene practice compared to hand washing. The gel will be useful for hospitals in rural areas lacking supply of clean water. Hand washing would be better to prefer when hands are visibly soiled.
References
Ejemot?Nwadiaro, R. I., Ehiri, J. E., Meremikwu, M. M., & Critchley, J. A. (2008). Hand washing for preventing diarrhoea. The Cochrane Library.
Erasmus, V., Daha, T. J., Brug, H., Richardus, J. H., Behrendt, M. D., Vos, M. C., & van Beeck, E. F. (2010). Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infection Control & Hospital Epidemiology, 31(03), 283-294.
Fung, I. C. H., & Cairncross, S. (2006). Effectiveness of handwashing in preventing SARS: a review. Tropical Medicine & International Health, 11(11), 1749-1758.
Gerding, D. N., Muto, C. A., & Owens, R. C. (2008). Measures to control and prevent Clostridium difficile infection. Clinical Infectious Diseases, 46(Supplement 1), S43-S49.
Guilhermetti, M., Wiirzler, L. M., Facio, B. C., da Silva Furlan, M., Meschial, W. C., Tognim, M. B., … & Cardoso, C. L. (2010). Antimicrobial efficacy of alcohol-based hand gels. Journal of Hospital Infection, 74(3), 219-224.
Ji, Y. J., & Jeong, J. S. (2013). Comparison of Antimicrobial Effect of Alcohol Gel according to the Amount and Drying Time in Health Personnel Hand Hygiene. Journal of Korean Academy of Nursing, 43(3).
Kampf, G., & Hollingsworth, A. (2008). Comprehensive bactericidal activity of an ethanol-based hand gel in 15 seconds. Annals of clinical microbiology and antimicrobials, 7(1), 1.
Kampf, G., & Loeffler, H. (2007). Prevention of irritant contact dermatitis among health care workers by using evidence-based hand hygiene practices: a review. Industrial health, 45(5), 645-652.
Liu, P., Yuen, Y., Hsiao, H. M., Jaykus, L. A., & Moe, C. (2010). Effectiveness of liquid soap and hand sanitizer against Norwalk virus on contaminated hands. Applied and environmental microbiology, 76(2), 394-399.
LoBiondo-Wood, G., Haber, J., Berry, C., & Yost, J. (2013). Study Guide for Nursing Research: Methods and Critical Appraisal for Evidence-based Practice. Elsevier Health Sciences.
Nthumba, P. M., Stepita?Poenaru, E., Poenaru, D., Bird, P., Allegranzi, B., Pittet, D., & Harbarth, S. (2010). Cluster?randomized, crossover trial of the efficacy of plain soap and water versus alcohol?based rub for surgical hand preparation in a rural hospital in Kenya. British Journal of Surgery, 97(11), 1621-1628.
Polit, D. F., & Beck, C. T. (2008) Nursing research: generating and assessing evidence for nursing practice Eighth Edition. Lippincott Williams &Wilkins. Philadelphia, Pa.
Rupp, M. E., Fitzgerald, T., Puumala, S., Anderson, J. R., Craig, R., Iwen, P. C., … & Sholtz, L. (2008). Prospective, controlled, cross-over trial of alcohol-based hand gel in critical care units. Infection Control & Hospital Epidemiology, 29(01), 8-15.
Sasahara, T., Hayashi, S., Hosoda, K., Morisawa, Y., & Hirai, Y. (2014). Comparison of hand hygiene procedures for removing Bacillus cereus spores. Biocontrol science, 19(3), 129-134.
Schneider, Z., & Whitehead, D. (2013). Nursing and midwifery research: methods and appraisal for evidence-based practice. Elsevier Australia.
Traore, O., Hugonnet, S., Lübbe, J., Griffiths, W., & Pittet, D. (2007). Liquid versus gel handrub formulation: a prospective intervention study. Critical Care, 11(3), 1.
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