NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

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Capella university

NURS-FPX 8030 Evidence-Based Practice Process for the Nursing Doctoral Learner

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Date

Hospital Acquired Infection Avoidance among ICU Patients through Hand Hygiene Protocol at Regional Memorial Hospital

Purpose: 

A comprehensive Hand Hygiene (HH) protocol-based policy aims to control and lower the patient security and care quality concerns of Hospital-Acquired Infections (HAIs) in Regional Memorial Hospital, particularly in its Intensive Care Units (ICUs). Patients in ICU are at an increased likelihood of HAI because of the frequent use of invasive operations and gadgets, immunodeficiency comorbidities, and fragility. The issue of HAIs is severe due to their increased healthcare costs, lengthening hospital stays, and worsening patients’ medical conditions. Every year, HAIs harm around 140,000 people around the world. Based on incidence surveys in the United States, ICUs account for 30.1% of HAIs (Blot et al., 2022).

Such infections are directly linked to the nation’s monetary damage; HAIs affect around 2 million individuals in the US each year, resulting in 90,000 fatalities and a cost of $28.1 to $45.2 billion (Marty et al., 2024). Regional Memorial Hospital has experienced a surge in HAIs, owing mainly to disparities in HAI prevention efforts and HH compliance. The Regional Memorial Hospital’s internal evidence revealed that 30% of patients suffer from HAIs in the ICU. The events of Central Line-Associated Bloodstream Infections (CLABSI) and Catheter-Associated Urinary Tract Infections (CAUTI) were 0.553 and 0.924 per 1,000 device days, surpassing national criteria (Leapfrog, 2024). CLASBI and CAUTI cause approximately 25.1% of patients to experience death in one year. This discrepancy causes an enormous gap in HAI prevention strategies, which should be addressed. 

NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

Reviewing earlier compliance audits and HAI control reports found that staff needed to follow current HAI preventive strategies such as HH. Given this practice gap, a clear policy is essential to guarantee that all divisions, notably ICU settings, comply with standardized HAI avoidance strategies. Research confirms the usefulness of the HH procedure and its adherence to minimizing HAI rates. For example, Boora et al. (2021) argued that increasing HH compliance lowers HAI rates. The lowest HAI was 4.26%, with a 63.66% compliance to HH. While HH compliance declined by 53.96%, the rate of HAI increased to 6.8%. The evidence was gathered utilizing databases such as PubMed, Cochrane Library, and CINAHL from observational studies, research on HAI prevention, and a comprehensive literature review while following the criteria for exclusion and inclusion.

The PICO(T) question that informs the policy is: In ICU patients at Memorial Regional Hospital (P), how does the implementation of hand hygiene protocol (I), as compared to current practices (C), affect the rate of HAIs (O) over 12 weeks (T)? Immediate intervention is required as HAIs among ICU patients result in extended hospitalizations, increased hospital expenses, and poor patient results. The HAI avoidance policy has an impact on patients and medical facilities. Such infections can cause diseases that extend the time required for full healing and necessitate extra treatments, which strains patients and hospitals. The HH protocol intervention strategy can improve patient safety and make it easier for health facilities to execute infection prevention policies. Further, this strategy will assist in minimizing the financial load of the hospital.

Population Affected by the Policy:

The intervention policy applies to all patients admitted to Regional Memorial Hospital’s ICU, focusing on critically ill patients who are most susceptible to HAIs, excluding the patient population of other settings. Such patients are frequently vulnerable because of intrusive therapies, including central lines and weakened immune systems (Blot et al., 2022). The policy also applies to medical personnel primarily accountable for carrying out and monitoring the daily HH regimen, including ICU physicians, nurses, and other infection prevention staff.

Hospital administration, quality assurance teams, and infection prevention staff are also affected because they will monitor adherence and determine how effectively the intervention functions to reduce HAI rates and improve care quality and patient results. The scope and depth of this issue are extensive as HAI affects those who are seriously ill in ICUs globally, adversely impacting their medical condition and leading to complications like sepsis. The problem of HAI is also prevalent in neonatal settings like neonatal ICUs, affecting the health of babies and jeopardizing their safety (Marty et al., 2024). The severity of infection contributes to morbidity, prolonged hospitalization, higher costs for healthcare, and increased fatality rates.

Definitions: 

• Hospital Acquired Infections (HAIs): Infections that are usually absent or can be incubated upon hospital admission. Such infections generally occur during hospitalization and emerge 48 hours after admittance (Monegro et al., 2023). Bacteria and other pathogens are abundant in hospitals, and insufficient HAI control procedures frequently cause these infections.
• Hand Hygiene Self-Assessment Framework (HHSAF): The World Health Organization (WHO) developed ICAT to conduct an incident examination of HH development and practices inside a particular healthcare organization. The tool helps identify major areas that require attention and change. The results can help establish a road map for the hospital HH advancement strategy (WHO, n.d.).
• Central Line-Associated Bloodstream Infections (CLABSI): Illnesses happen when pathogens, typically fungi or bacteria, penetrate the circulatory system through a central line due to an unsanitized method. The central line is a tube that healthcare workers commonly insert into a major neck vein or abdomen to administer drugs or fluids or obtain blood for clinical evaluations (Centers for Disease Prevention and Control, 2024). Such infections are common adverse effects among ICU patients receiving invasive treatment.

NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

• Catheter-Associated Urinary Tract Infections (CAUTI): Illness occurs when fungi or bacteria penetrate the urinary tract through a tube or catheter due to poor sterilization methods (Rubi et al., 2022).
• Hand Hygiene Protocol: The protocol refers to guidelines for HH to avoid HAIs. Guidelines comprise the HH method of hand preparation and sanitization before surgical procedures, the use of HH chemicals for washing hands, such as soap and sanitizer, the utilization of Alcohol-Based Hand Rub (ABHR) and gloves, appropriate skin care, and staff training on HH methods (Buković et al., 2021).
• Hand Hygiene Compliance: Hand hygiene compliance is the adherence of medical staff to approved HH procedures at the appropriate times during patient care to prevent HAI. Compliance with HH entails cleaning your hands with water and detergent or using a suitable method to eliminate infection-causing agents like bacteria (Krishnamoorthy et al., 2023).
• PICO(T) Question: An effective method for formulating clinical trial inquiries. PICO(T) entails Population, Intervention, Comparison, Outcome, and Time, allowing researchers to focus the investigation on particular aspects of health services or patient security concerns. 

Policy Statement:

Resolving issues related to patient safety to improve medical results and reduce HAI incidences among ICU patients, Regional Memorial Hospital has committed to establishing a complete HH protocol program in its medical facility, particularly in ICUs, within 12 weeks. To lower HAI by up to 55% in 12 weeks, this policy ensures that evidence-based protocols are followed consistently. The ICU personnel will be properly educated and trained in HH practices, and the HHSAF and Infection Control Assessment Tool (ICAT) will strictly enforce HH protocol adherence. The Regional Memorial Hospital is dedicated to improving patient safety by integrating and adhering to research-based HH procedures. The quality advancement plan of Regional Memorial Hospital aligns with WHO and Centers for Disease Prevention and Control recommendations, which is a vital step in improving patient results and care quality.

Procedure:

The HH program will be executed over 12 weeks. The plan comprises setting up automatic soap and sanitizer dispensers and HH surveillance tools. The approach additionally involves comprehensive staff training on HH protocol and practices, monitoring compliance, and evaluating the efficiency of HAI reduction among ICU patients.

Phase 1: Conducting Staff Training on Hand Hygiene Practices (Weeks 1 to 4) 

Participants: Training sessions will be conducted for nurses and doctors to boost HH practices. ICU nurses and doctors are anticipated to follow HH practices when treating ICU patients. Further, the HAI control team oversees HH compliance and performs hygiene and sensitization procedures. Finally, ICU supervisors ensure that supplies are available and staff members are supported in adopting HH practices.

Training Sessions: Educational sessions will be conducted, emphasizing the role of HH practices in daily routines to avoid HAIs. The training will focus on introducing the importance of hand hygiene and providing an overview of the HH protocol. Trainers will also demonstrate proper hand-washing methods and the application of hand sanitizers to boost HH compliance. Koota et al. (2024) showed that educational intervention improves medical staff comprehension, skills, self-efficiency, and behaviors to avoid HAIs and their management. Virtual and online modes will be adopted to offer staff training.

Supplies Needed: Educational materials such as booklets and posters, soap and alcohol-based sanitizers, and feedback questionnaires will be needed.

Training Assessment: In the fourth week, training evaluation will be conducted using pre- and post-intervention assessment and a staff survey. The review before and after training will aid in determining staff comprehension, and the survey will identify staff compliance with HH practices.

Phase 2: Integration of Automated Sanitizer and Soap Dispenser (Weeks 5 to 8)

Daily Hand Hygiene Protocol: Comprehensive instructions for using automated dispensers will be provided to ensure effective adoption for HH compliance, highlighting their significance in lowering infection transmission and risk of HAIs.

Participants: Vital stakeholders for the effective installation of automated sanitizer dispensers include the hospital manager, who will oversee the entire integration process, coordinate between teams, and ensure timely completion. The maintenance staff will install the automated dispensers and ensure they function correctly. Lastly, the Infection prevention staff will deliver instructions on the adequate use of the dispensers and monitor staff adherence.

Supplies Needed: Financial resources will be needed to purchase supplies like automated soap and sanitizer dispensers and refills.

Monitoring Compliance: The infection prevention staff will monitor and analyze the medical staff’s compliance with HH practices and utilization of dispensers for HH by using tools like ICAT and HHSAF. These tools will offer comprehensive analysis and provide insight into areas for further advancement (WHO, n.d.). 

Phase 3: Implementation of Hand Hygiene Compliance Surveillance Tool for Evaluation and Feedback (Week 9 to 12)

Participants: Integration of the HH compliance tracking tool is crucial for continuous tracking and real-time feedback on staff HH compliance. Several key participants will be involved, including medical staff who are vital to performing HH based on standard guidelines. Technological staff will be needed to integrate the tracking system with the hospital’s EHR system. Infection prevention staff will monitor HH compliance.

]Data analysts will assess the real-time data of HH compliance and HAI rate from dashboard data, offering deep insight into the efficacy of HH protocol. Wang et al. ( 202), asserted that implementing an HH monitoring system is crucial to improve HH compliance among staff by reminding medical staff about their HH responsibilities through alerts. Continuous and real-time surveillance ultimately aid in reducing the risks of HAIs. 

Effectiveness Assessment: The data analyst and Infection prevention staff will analyze real-time data generated through the monitoring system. Key Performance Indicators (KPIs), including staff compliance rate and HAI rate before and after intervention, will be measured to assess the efficacy of the HH protocol. 

NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

Feedback Mechanism: The surveillance tool will offer real-time feedback, aiding in identifying areas that need further advancement. Weekly or monthly reports summarizing compliance data will be shared with all stakeholders. The feedback mechanism is crucial, involving real-time alerts from automated systems, regular reports summarizing compliance data, meetings to discuss findings, and developing a setting of constant improvement.

Supplies Needed: Data analysis software, surveillance tools, posted HH reminders, and all other relevant supplies will be required to ensure staff compliance and efficacy of HH practices to avoid HAI in the hospital.

The quality enhancement efforts aim to promote HAI avoidance at Regional Memorial Hospital through improving HH practices and compliance with standard guidelines, ultimately boosting patient results and treatment quality.

References:

Blot, S., Ruppé, E., Harbarth, S., Asehnoune, K., Poulakou, G., Luyt, C.-E., Rello, J., Povoa, P., Bouadma, L., Timsit, J.-F., & Zahar, J.-R. (2022). Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies. Intensive and Critical Care Nursing, 70, 103227. https://doi.org/10.1016/j.iccn.2022.103227

Boora, S., Singh, P., Dhakal, R., Victor, D., Gunjiyal, J., Lathwal, A., & Mathur, P. (2021). Impact of hand hygiene on hospital-acquired infection rate in neuro trauma ICU at a Level 1 Trauma Center in the National Capital Region of India. Journal of Laboratory Physicians, 13(02), 148-150. https://doi.org/10.1055/s-0041-1730820

NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

Buković, E., Kurtović, B., Rotim, C., Svirčević, V., Friganović, A., & Važanić, D. (2021). Compliance with hand hygiene among healthcare workers in preventing healthcare associated infections–A systematic review. Journal of Applied Health Sciences, 7(1), 57-69. https://doi.org/10.24141/1/7/1/6

Centers for Disease Prevention and Control. (2024). Central Line-Associated Bloodstream Infection (CLABSI) Basics. Centers for Disease Prevention and Control.gov. https://www.cdc.gov/clabsi/about/index.html

Koota, E., Kaartinen, J., & Melender, H. L. (2024). Impact of educational interventions for professionals on infection control practices to reduce healthcare-associated infections and prevent infectious diseases: A systematic review. Collegian Journal of the Royal College of Nursing Australia, 31(4), 218–231. https://doi.org/10.1016/j.colegn.2024.04.006

Krishnamoorthy, Y., M, K., Kuberan, D., Krishnan, M., & Tondare, D. (2023). Compliance with hand hygiene practices and its appropriateness among healthcare workers during COVID-19 pandemic in public health facilities of Tamil Nadu, India. Heliyon, 9(4), e15410. https://doi.org/10.1016/j.heliyon.2023.e15410

NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

Leapfrog. (2024). Hospital details table. Hospitalsafetygrade.org. https://www.hospitalsafetygrade.org/table-details/memorial-regional-hospital

Marty, D., Sorum, K., Smith, K., Nicoski, P., Sayyed, B. A., & Amin, S. (2024). Nosocomial infections in the neonatal intensive care unit. NeoReviews, 25(5), e254-e264. https://doi.org/10.1542/neo.25-5-e254

Monegro, F. A., Muppidi, V., & Regunath, H. (2023). Hospital-acquired infections. StatPearls. https://pubmed.ncbi.nlm.nih.gov/28722887/

Rubi, H., Gargi Mudey, & Radha Kunjalwar. (2022). Catheter-Associated Urinary Tract Infection (CAUTI). Cureus, 14(10), e30385. https://doi.org/10.7759/cureus.30385

Wang, C., Jiang, W., Yang, K., Yu, D., Newn, J., Sarsenbayeva, Z., & Kostakos, V. (2021). Electronic monitoring systems for hand hygiene: Systematic review of technology. Journal of Medical Internet Research, 23(11), e27880. https://doi.org/10.2196/27880

WHO. (n.d.). Hand Hygiene Self-Assessment Framework 2010. World Health Organization.int. https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/hand-hygiene/monitoring/hhsa-framework-october-2010.pdf?sfvrsn=41ba0450_6

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