Introduction
Hospital-acquired infections (HAIs), otherwise known as healthcare-associated infections, are one of the primary patient safety concerns during hospitalization and in-patient treatment. Bacterial infections can cause serious illness, treatment complications, and death. HAI rates vary but affect at least 1 in 25 hospitalized patients and can reach as high as 20% leading to tens of thousands of deaths and costing the U.S. healthcare system billions of dollars in expenses each year (ODPHP, 2019). Despite significant research and measures taken against HAIs in the past two decades, it remains a relevant and concerning issue, particularly with increasing populations and utilization of healthcare services.
HAIs are directly caused by a bacterial infection in various aspects of hospital treatment, including surgical sites, injections, catheters, central-line, and simple communicable diseases. Therefore, one of the primary origins of infection is hand hygiene which hospital staff is expected to maintain as they interact with patients and elements listed above. Therefore, the PICO question established for this review states, “For adult patients in critical care (P), does implement hand hygiene protocol among healthcare workers and patients (I), in comparison to lack of concrete guidelines or training (C), help reduce the rate of hospital-acquired infections (O)?” The purpose of this paper is to review the literature regarding the topic of HAIs and discuss a hand hygiene protocol as a preventive measure.
Methods
Research for this paper was conducted in a standard manner. First, the author familiarized themself with the topic using reliable government websites such as the CDC and ODPDP. Using acquired knowledge, databases were searched for relevant research articles on hand hygiene and HAIs. The primary search websites used were Google Scholar and the U.S. National Library of Medicine National Institutes of Health, which also links to a variety of databases such as PubMed and PMC. The only exclusion criteria set was that the articles be from peer-reviewed journals published in the last 5 years (since 2014). Terms used for the search included: hospital-acquired infections, healthcare-associated infections, hand hygiene, hand washing, patient safety, nurse, and critical care. Articles that were considered useful were identified by title and journal name and examined further by reading the abstract to determine whether they fitted for this literature review. According to instructions, six articles were chosen; three of the articles selected came from nursing-focused journals, which were identified based on their title and researched background. Most of the studies adhered to Levels I and II of evaluating evidence to ensure the high validity of the research.
Results
The prevalence of HAIs and adherence to hand hygiene is one of the central concepts of clinical trials on the topic. A systematic review by Kingston, Connell, and Dunne (2016) aimed to determine the primary factors regarding hand hygiene compliance among healthcare professionals. Data were collected by reviewing the literature published by the World Health Organization over a period of 4 years with 16 clinical trials meeting criteria. The study found hand-hygiene compliance to be at 34.1% and increasing by an average net improvement of 23%, with multimodal interventions of varying design being most effective (Kingston et al., 2016). The strength of this article is its comprehensive overview of the issue and the in-depth analysis of clinical studies identifying limitations to the research. A weakness of this study can be identified as using outdated literature and having a lack of focus.
Another study by Doronina, Jones, Martello, Biron, & Lavoie-Tremblay (2017) presents a systematic review to determine the best interventions for hand hygiene compliance among nurses. A search of the literature was conducted using guidelines for systematic reviews and appropriate medical databases, with a total of six studies selected. Findings suggest that both multimodal and singular interventions are effective, particularly focusing on education, but some lack sustainability in compliance afterward. The strength of the article is its focus solely on nurses, while weaknesses include poor reporting on some of the examined data and the possibility of the Hawthorne effect since nothing is directly observed.
Since it was established that education is a key aspect to compliance, an article by Labrague, McEnroe-Petitte, van de Mortel, and Nasirudeen (2017) seeks to determine the extent of hand-hygiene knowledge in nursing students. The study is a systematic review of scientific articles on the topic of nursing student knowledge, with 19 studies fitting the final criteria. The authors found that student nurses generally demonstrated low to moderate knowledge and consequent compliance in this population, surprisingly higher than in medical students. Suboptimal knowledge can be traced back to the lack of proper inclusion of the topic of educational material as well as organizational policy. The strength of this study can be attributed to the unique focus on nursing education, while the limitation can include the argument that the results are not applicable since the subjects are not working registered nurses.
While the systemic review has its benefits, it is important to examine practical applications of hand hygiene. In a study by Musu et al. (2017), the authors examine the existing policies and protocols for infection control and hand hygiene in six intensive care units as well as the compliance among healthcare professionals in these facilities. This was a prospective observational study with data collection, which included hospitals of various sizes. It was found that only half of the required protocols were available, with 12 out of 15 for hand hygiene. Compliance ranged as well from 3% to full adherence (Musu et al., 2017). The strength of the study is its use of the observational method approved by the WHO to observe hand hygiene, while a potential weakness includes the presence of the Hawthorne effect since it was a direct observation study.
Finally, it is necessary to determine the effectiveness of interventions. Haverstick et al. (2017) published a study to determine if improvement of patient hand hygiene has an impact on staff compliance and HAI levels. Patients were provided with hygiene tools such as hand sanitizer and taught about its importance by nurses. It was found that HAI rates declined after the intervention, while both staff and patients took more opportunities to improve hand hygiene. The strength of this study is its focus on the approach to the issue through patient education, while its limitation is a limited sample and a lack of a randomized control group.
Discussion
All the literature reviewed for the topic acknowledges the seriousness of HAIs as a critical issue in health care. There is also a general agreement that hygiene is a primary cause of HAIs in critical care settings, therefore compliance to protocols such as handwashing is vital. However, several articles found that compliance remains low to moderate, based both on observation studies as well as systemic reviews (Kingston et al., 2016, Musu et al., 2017). It is unclear why such a fundamental concept remains a priority issue regarding hygiene compliance. Labrague et al. (2017) suggest that this is due to poor knowledge and understanding of hygiene and its impact on HAI rates, stemming from insufficient education on the topic in nursing and medical institutions. Haverstick et al. (2017) determined that patient education of hand hygiene has an impact on staff compliance and overall HAI rates. Meanwhile, Musu et al. (2017) offer a perspective on protocols and policy, highlighting that it is often lacking, or medical professionals are not provided with appropriate means to follow them. Finally, regarding interventions, it was found that multimodal approaches are most effective, but there are still issues regarding adherence in the months post-intervention (Kingston et al., 2016; Fox et al., 2017).
In summary, hand hygiene remains an essential aspect and procedure for the prevention of HAIs, but compliance remains low, leading to the need for interventions in the form of education and protocols. There was no evident disagreement established among the studies, while most came to similar conclusions based on the synthesis. It is important to note that studies examined both nurses and physicians across the world, and the results were inherently similar. This suggests a strong need for addressing hand hygiene protocol in a systemic and continuous approach through interventions and education at all levels. The general research area has the strength of identifying interventions and methods which have an impactful influence on nursing practice. If a limitation was to be identified across all studies is the presence of the Hawthorne observer effect since it is an aspect of practice that must be observed and studied.
Conclusion
HAIs are one of the most critical patient safety concerns affecting thousands of hospitalized individuals and leading to severe medical complications. Hand hygiene is a simple but important procedure for the management of HAIs. This literature review identified that there is poor compliance with hand hygiene, requiring interventions in education and protocols to increase it. It has implications for practice by allowing medical professionals to be aware of the impact of hand hygiene on HAI rates as well as recommend the development of appropriate protocol measures to address the issue in the long term by improving nurse compliance with hand hygiene guidelines.
References
Doronina, O., Jones, D., Martello, M., Biron, A., & Lavoie-Tremblay, M. (2017). A systematic review on the effectiveness of interventions to improve hand hygiene compliance of nurses in the hospital setting. Journal of Nursing Scholarship, 49(2), 143-152. Web.
Haverstick, S., Goodrich, C., Freeman, R., James, S., Kullar, R., & Ahrens, M. (2017). Patients’ hand washing and reducing hospital-acquired infection. Critical Care Nurse, 37(3), 1-8. Web.
Kingston, L., O’Connell, N. H., & Dunne, C. P. (2016). Hand hygiene-related clinical trials reported since 2010: A systematic review. Journal of Hospital Infection, 92(4), 309–320. Web.
Labrague, L. J., McEnroe-Petitte, D. M., van de Mortel, T., & Nasirudeen, A. M. A. (2017). A systematic review on hand hygiene knowledge and compliance in student nurses. International Nursing Review, 65(3), 336-348. Web.
Musu, M., Lai, A., Mereu, N. M., Galletta, M., Campagna, M., Tidore, M., … Coppola, R. C. (2017). Assessing hand hygiene compliance among healthcare workers in six Intensive Care Units. Journal of Preventive Medicine and Hygiene, 58(3), 231-237. Web.
ODPHP. (2019). Health care-associated infections. Web.