Clinical scenario report

Clinical scenario report
1. INTRODUCTION.
About 200,000 healthcare-associated infections (HAIs) are acquired by patients whilst receiving some form of health care in Australia in a one year period (AIHW, 2011). National hand hygiene compliance rates are low, 68.3%, which is concerning given that hand hygiene is the single most important task health care workers can to do prevent HAIs (Girou, Loyeau, Legrand, Oppein, & Brun-Buisson, 2002, p.362). The purpose of this report is to investigate the best methods of hand hygiene to decrease the rate of cross-infection in a hospital setting. To focus the search, this report defines ‘best methods of hand hygiene’ as the best products to wash one’s hands with. Therefore, methods of hand-drying and hand washing protocols are excluded, as well as literature discussing compliance rates and educational interventions.
2. METHODOLOGY.
Practice Question: what are the best methods of hand hygiene to decrease the rate of cross-infection in a hospital setting?
PICOT:
Population: hospital-based personnel, i.e. health-care workers, students.
Intervention: products to wash your hands with, including liquid soap, 70% alcohol based hand rub, chlorhexidine gluconate 4%, and 10% povidone-iodine. (N.B. Interventions of compliance, education and hand-drying were NOT measured).
Control: other products to wash your hands with.
Outcome: infection rates and microbial counts on hands.
Type of study: randomised-controlled trial or experimental studies.
The Search Process: used keywords (or MESH/subject headings) combined with Boolean phrases “and”, then limited the final result to randomised-controlled trial.
1. Hand hygiene
2. Cross infection
3. Hospital units or hospitals
4. Hospital* or unit*
5. 3 or 4
6. 1 and 2 and 5
7. Limit 6 to randomised-controlled trials (RCTs), human subjects and English.
•Inclusion criteria: RCTs or experimental studies, English and human subjects.
•Exclusion criteria: non-English studies, non-human subjects, studies below level II (controlled trial without randomisation, case-control or cohort study, systematic review of qualitative or descriptive studies, qualitative or descriptive study, expert opinion or consensus).
Hand-drying, hand-washing protocols, compliance and educational interventions were not made exclusion criteria by applying limits to the database or negative keywords in the initial search. Instead the abstracts of each article from the final search result were read and assessed for appropriateness (screening), as the number generated was a manageable size to appraise (n=77, see flow diagram on next page). 71 of these 77 articles were excluded, essentially because they focused on compliance, educational interventions, hand drying methods, and hand-washing protocols. It was established at the beginning of the report that ‘best methods of hand hygiene’ was defined as the best products to wash one’s hands, which guided the inclusion and exclusion criteria. Six full-text articles were printed; with one of these articles being excluded as the setting was a university campus instead of a hospital setting (incorrect population). The five studies that were kept investigated the best methods of hand hygiene (i.e. different products to wash one’s hands) to decrease the rate of cross-infection in a hospital setting.
•Study types included: level II studies – RCTs or experimental studies.
•Places/databases searched: Pubmed, CINAHL, and Medline.
Critical Appraisal Process: Is the study design valid?
N.B. The criteria used to evaluate the remaining five study designs’ validity was that used by Fineout-Overholt, Melnyk, Stillwell & Williamson (2010), prescribed reading 2 of the week 7 reading list NURS1007.
Rapid Critical Appraisal Questions (Fineout-Overholt et al., 2010, pp. 44-45):
1. Are the results of the study valid?
A. Were the subjects randomly assigned to the intervention and control groups?
B. Was random assignment concealed from the individuals enrolling the subjects?
C. Were the subjects and providers blind to the study group?
D. Were reasons given to explain why subjects didn’t complete the study?
E. Were the follow-up assessments long enough to fully study the effects of the intervention?
F. Were the subjects analysed in the group to which they were randomly assigned?
This method of analysis is termed “intention-to-treat analysis”, whereby researchers keep participants in their assigned groups when conducting the analysis and intends to reduce possible bias (Fineout-Overholt et al., 2010, p. 46).
G. Was the control group appropriate?
H. Were the instruments used to measure the outcomes valid and reliable?
I. Were the demographics and baseline clinical variables of the subjects in each of the groups similar?
2. What are the results?
A. How large is the intervention or treatment effect?
Indicated by the odds ratio (OR), which measures the association between an intervention and an outcome (Fineout-Overholt et al., 2010, p. 46).
B. How precise is the intervention or treatment?
The intervention or treatment is significant if the P-value is less than 0.05 (P < 0.05) and the confidence interval (CI) for OR does not include 1.0, meaning the findings are reliable. Findings that are not statistically significant could have been obtained by chance, so cannot be confidently put into practice (Fineout-Overholt et al., 2010, p. 48). 3. Will the results help me in caring for my patients? A. Were all clinically important outcomes measured? E.g. cost etc. B. What are the risks and benefits of the treatment? C. Is the treatment feasible in my clinical setting? – a hospital. D. What are my patients’ and their families’ values and expectations for the outcome and the treatment itself? 3. RESULTS Flow diagram from: Moher, Liberati, Tetzlaff, Altman, & the PRISMA Group. (2009). Records identified through database searching (n = 87): CINAHL, Medline, Pubmed. Identification Additional records identified through other sources (n = 0) Records after duplicates removed (n = 77) Records screened (n = 77) Records excluded (n = 71) See exclusion criteria for reasons. Full-text articles assessed for eligibility (n = 6) Full-text articles excluded (n =1) Reason: the setting was a University campus & not a hospital Studies included in qualitative synthesis (n = 0) Studies included in quantitative synthesis (RCTs) (n = 5) Screening Eligibility Included Summary of Critical Appraisal Results (Fineout-Overholt et al., 2010 Criteria): READING 1: Girou, Loyeau, Legrand, Oppein, & Brun-Buisson, 2002. Are the results valid? Ask: Were the subjects randomly assigned to the intervention and control groups? Yes Was random assignment concealed from the individuals enrolling the subjects? Unknown Were the subjects and providers blind to the study group? Yes Were reasons given to explain why subjects didn’t complete the study? N/A Were the follow-up assessments long enough to fully study the effects of the intervention? Yes – observed 114 patient care activities with HH. Were the subjects analysed in the group to which they were randomly assigned? Yes – intention-to-treat principle Was the control group appropriate? Yes Were the instruments used to measure the outcomes valid and reliable? Yes – bacterial counts (%) from agar plates before and after HH. Were the demographics and baseline clinical variables of the subjects in each of the groups similar? Yes – tables provided. Summary of Critical Appraisal Results (Fineout-Overholt et al., 2010 Criteria): READING 1 Continued: Girou, Loyeau, Legrand, Oppein, & Brun-Buisson, 2002. What are the results? Ask: How large is the intervention or treatment effect? Handrubbing 83% bacterial reduction vs handwashing with antiseptic soap (chlorhexidine gluconate 4%) 58% reduction. P value=0.012 How precise is the intervention or treatment? 95% CI (8% to 44%) Will the results help me in caring for my patients? Ask: Were all clinically important outcomes measured? Yes – mean and median bacterial counts before and after HH for handrubbing with alcohol based gel and handwashing with antiseptic soap. The median duration of HH for both hand products was also measured. What are the risks and benefits of the treatment? This RCT did not disrupt routine practice and can benefit patients by determining whether alcohol hand sanitiser or antiseptic soap is more effective in reducing hand contamination. Is the treatment feasible in my clinical setting? (i.e. has enough time been allowed to measure outcomes & the process of implementing the intervention). Yes – HH is required before and after every patient encounter, so is integral to routine practice. What are my patients’ and their families’ values and expectations for the outcomes and the treatment itself? Patients and families expect quality care and safe care whilst in hospital, i.e. they expect health care workers to wash their hands before routine patient care. Table above: Summary of Critical Appraisal Results (Fineout-Overholt et al., 2010 Criteria): READING 1 Continued: Girou, Loyeau, Legrand, Oppein, & Brun-Buisson, 2002. Summary of Critical Appraisal Results (Fineout-Overholt et al., 2010 Criteria): READING 2: Guilhermetti, Hernandes, Fukushigue, Garcia, & Cardoso, 2001. Are the results valid? Ask: Were the subjects randomly assigned to the intervention and control groups? No Was random assignment concealed from the individuals enrolling the subjects? No Were the subjects and providers blind to the study group? No Were reasons given to explain why subjects didn’t complete the study? n/a Were the follow-up assessments long enough to fully study the effects of the intervention? Yes Were the subjects analysed in the group to which they were randomly assigned? n/a: latin square statistical design, with two 5×4 randomised blocks. All volunteers used all hand products once. Was the control group appropriate? In each experiment one different volunteer acted as a control. Total participants: 2 males and 3 females. Were the instruments used to measure the Yes – obtained viable counts of outcomes valid and reliable? MRSA on mannitol salt agar with oxacillin from dilution by the modified drop-plate technique. Calculated removal rate of MRSA using log10 reduction factors (RF). Had a 7 day period inbetween experiments to allow normal skin flora to repair itself. Were the demographics and baseline clinical variables of the subjects in each of the groups similar? In each experiment one different volunteer acted as a control, whose hands were contaminated but not treated with the hand cleansing product. Total participants: 2 males and 3 females. Table above: Summary of Critical Appraisal Results (Fineout-Overholt et al., 2010 Criteria): READING 2: Guilhermetti, Hernandes, Fukushigue, Garcia, & Cardoso, 2001. Summary of Critical Appraisal Results (Fineout-Overholt et al., 2010 Criteria): READING 2 Continued: Guilhermetti, Hernandes, Fukushigue, Garcia, & Cardoso, 2001. What are the results? Ask: How large is the intervention or treatment effect? RF=reduction factor. FIRST BLOCK: Significant difference between treatments as P<0.05. 10% PVP-I (RF 3.76) and 70% ethyl alcohol (RF 3.51) had significantly higher removal rates of MRSA than plain liquid soap (RF1.96) and 4% chlorhexidine (RF1.91). SECOND BLOCK: 10% PVP-I (RF4.39) and 70% ethyl alcohol (RF3.27) were significantly more effective in remove MRSA from hands than plain liquid soap (RF1.77) and 4% chlorhexidine (RF1.37; P<0.05). Plain liquid soap was significantly more effective than chlorhexidine 4% detergent in removing MRSA from hands. How precise is the intervention or treatment? Confidence intervals (CI) not given in this study. Will the results help me in caring for my patients? Ask: Were all clinically important outcomes measured? CI could have been measured – would have provided precision of intervention. What are the risks and benefits of the treatment? HH is the most important procedure in preventing HAIs. Health literature has proven that MRSA can be carried transiently on the hands of health care workers, so HH is important not only to prevent HAIs but antibiotic resistant HAIs. Is the treatment feasible in my clinical setting? (i.e. has enough time been allowed to measure outcomes & the process of implementing the intervention). Yes – HH is an integral part of routine patient care. What are my patients’ and their families’ values and expectations for the outcomes and the treatment itself? Patients expect healthcare workers to wash their hands before and after delivery of patient care. Table above: Summary of Critical Appraisal Results (Fineout-Overholt et al., 2010 Criteria): READING 2 Continued: Guilhermetti, Hernandes, Fukushigue, Garcia, & Cardoso, 2001. Summary of Critical Appraisal Results (Fineout-Overholt et al., 2010 Criteria): READING 3: Hajipour, Longstaff, Cleeve, Brewster, Bint & Henman, 2006. Are the results valid? Ask: Were the subjects randomly assigned to the intervention and control groups? Yes – using a randomisation table. Was random assignment concealed from the individuals enrolling the subjects? No. But microbiologist assessing bacterial colonies present on agar plate after 24h and 48h of incubation was blinded to the washing protocol used. Were the subjects and providers blind to the study group? No. But microbiologist assessing bacterial colonies present on agar plate after 24h and 48h of incubation was blinded to the washing protocol used. Were reasons given to explain why subjects didn’t complete the study? n/a Were the follow-up assessments long enough to fully study the effects of the intervention? Yes – 41 procedures and 82 episodes of handwashing included in the study. Were the subjects analysed in the group to which Yes they were randomly assigned? Was the control group appropriate? Could have been more information, assumed orthopaedic surgeons are from the same hospital/surgery. Were the instruments used to measure the outcomes valid and reliable? Yes – Fisher’s exact test. Surgeon scrubbed in appropriate product, gloved, performed procedure, then gloves were removed, and fingertips from each hand placed on agar plate. Were the demographics and baseline clinical variables of the subjects in each of the groups similar? Unknown – orthopaedic surgeons – more information required, are they at the same hospital? What are the results? Ask: How large is the intervention or treatment effect? Four hands (8%) were contaminated in the chlorhexidine group compared to 19 (34%) in the alcohol group. Fisher’s exact test showed that there is a significantly higher risk of contamination using alcohol gel compared to chlorhexidine (P=0.002). The average bacterial colony count was also much higher in the alcohol group (20) compared to the chlorhexidine group (5). There was no relationship between the length of surgery and the degree of contamination (P=1.12, not significant as P > 0.05).
How precise is the intervention or treatment?
Confidence intervals (CI) were not given in the results of this study.
Will the results help me in caring for my patients? Ask:
Were all clinically important outcomes measured?
Yes – bacterial contamination on surgeons’ hands when washed with alcohol compared to chlorhexidine.
What are the risks and benefits of the treatment?
One of the factors affecting patient’s infection risk during a surgical procedure is the surgeon’s method of hand washing prior to the surgery, as between 50-67% of gloves are perforated during joint replacement operations (Hajipour et al., 2006).
It is therefore of benefit to the patient to know the most effective handwashing product for reducing bacterial contamination of surgeon’s hands prior to surgery.
Is the treatment feasible in my clinical setting? (i.e. has enough time been allowed to measure outcomes & the process of implementing the intervention).

 
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