Clinical Guidelines Paper

Posted: January 4th, 2023

Clinical Guidelines Paper

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Clinical Guidelines Paper

Nosocomial or hospital-acquired infections (HAI) are a significant problem in many healthcare facilities. The ongoing Covid-19 pandemic has unearthed the dangers nosocomial infections portend to patients and healthcare workers (Chou et al. 2020). In my unit, were encountered the spread of Covid-19 among patients and healthcare professionals, and the devastating health implications of a highly-infectious virus that was threatening the known HAI prevention strategies. My colleagues worked diligently to contain the spread of the disease among patients and healthcare professionals because covid-19-related nosocomial infections still pose a serious threat to nurses, who comprise the highest proportion of frontline healthcare professionals fighting the pandemic. I chose to implement a prevention of nosocomial infections as the current standardized guideline during highly-infectious pandemics. The relevant guideline can be retrieved from https://www.cdc.gov/coronavirus/mers/infection-prevention-control.html. The Centers for Disease Control and Prevention is an America federal agency that identifies, studies, and develops protective measures against health threats, like highly-infectious diseases. It plays a critical role in developing and furnishing evidence-based infection prevention and control (IPC) guidelines to the entire nation and the rest of the world, alongside those developed by the World Health Organization (WHO) (Houghton, et al., 2020).

Most of the hospital-acquired infections related to the coronavirus disease afflict the elderly disproportionately. According to Carter et al. (2020), the global prevalence of hospital-acquired infections was 8.7%, posing a significant economic and healthcare burden across the highly-developed and underdeveloped countries. Surgical cuts and urinary and respiratory tracts are the common sites for contracting nosocomial infections before the advent of the covid-19 pandemic. However, following the SARS-CoV-2 outbreak in late 2019, individuals with a history of trauma, are immunosuppressed, have extended antibiotic usage, admitted to intensive care and use an embedded catheter, and are aged above 70 years at most at risk of contracting a nosocomial injection, particularly related to covid-19. Although the previous experience with other viral diseases, such as Ebola, severe acute respiratory syndrome (SARS), and Middle East Respiratory Syndrome (MERS) was characterized by high rates of infection transmission among healthcare workers and patients, hospital-acquired covid-19 presented a higher rate, estimated at 41% in China (Carter, et al. 2020). The asymptomatic patients, the 5-14 day incubation period, and the erroneous application of personal protective equipment by healthcare workers have been attributed to these high infection rates (Carter, et al. 2020; Phan, et al., 2019). Nurses are critical to the prevention of nosocomial infection, considering that they disproportionately exposed to Covid-19 patients and likely to propagate nosocomial infection to their colleagues and patients through improper use of personal protective equipment. The lack of sufficient pandemic control training and fatigue from work overload among nurses are some of the promoters of hospital-acquired infections during infectious diseases pandemics

Research Evidence

Research Article #1

Research Article (provide FULL reference): English, K. M., Langley, J. M., McGeer, A., Hupert, N., Tellier, R., Henry, B., … & Pourbohloul, B. (2018). Contact among healthcare workers in the hospital setting: developing the evidence base for innovative approaches to infection control. BMC Infectious Diseases, 18(1), 1-12. https://doi.org/10.1186/s12879-018-3093-x.
Setting	The setting of this study was at Canadian hospitals that are based in urban centers and are affiliated to universities. Architectural details of the hospitals were provided to provide an understanding of the movement within the facilities and the likelihood and frequency of contact among healthcare workers and between them and their patients.
Purpose	The purpose of this study was to determine the relationship between the movement of healthcare workers and their contact patterns, and hospital-acquired infections in healthcare facility.
Research design	A qualitative research using the cross-sectional study design was conducted. In this descriptive study, the researchers sought describe the locations in a hospital that movement and contact was likely to lead to contracting infections.
Sample studied	Purposive sampling was used to recruit 3048 healthcare workers to participate in the survey. The healthcare workers were invited through posters, emails, and personal invitation. The participants were drawn from three Canadian hospitals affiliated to urban universities. The participant were drawn from numerous department and units in the hospitals and categorized as administrative/support staff, nursing practitioners, physicians, and ‘other’ healthcare workers.
Findings/Results	The participants had a media age of 42 years, comprised of 81 % female, and visited between an average of 3.69 and 3.88 floors of their healthcare facilities every week. Physicians visited most while nurses visited the least number of locations in the hospitals per week. Moreover, the healthcare workers movement and contact patterns varied significantly by their roles in the hospitals. While nurses reported having elongated direct contact with patients, non-nurse and non-physician workers had significantly higher contact compared to other work-related roles in the hospitals. Within-ward movement by the nurses presented a lower infection spreading risk compared to the mobility of, especially, personal care attendants and respiratory therapists. Moreover, public locations within the hospital were the most frequented locations in the hospitals, albeit for limited periods.
Limitations	This study was limited by the reliance on the individuals’ recollection of their movement within the hospitals. In addition, the hospital building floors was regarded as the smallest spatial unit, ignoring the granular depiction of the network nodes presented by the diverse aspects within each floor.
Level of Evidence and Justification for Level.	This study is ranked in level VI of the hierarchy of evidence. The evidence is drawn from a single qualitative study depicting the movement and contact pattern of healthcare workers.
Are Findings Valid?	The findings have some validity because they describe the degree of contact and movement along hospital floors as the intended measurable variables. However, defining locations as floor denied the study the accuracy and granularity of the findings about the risk presented by movement and contact in a hospital setting.
Importance of Findings	The study provided information that can inform and direct interventions against hospital-acquired infections, thus optimizing infection control strategies.

This study is descriptive with a level VI ranking in evidence hierarchy. It lacks an experimental design and therefore has extraneous variables beyond the researchers control or that were ignored in the study. For instance, floors in hospitals are not necessarily related to specific medical departments or wards, and therefore, cannot be related to the roles of the healthcare workers. This study may not provide practice-changing evidence when used in isolation.

Research Article #2

Research Article (provide FULL reference): Phan, L. T., Maita, D., Mortiz, D. C., Weber, R., Fritzen-Pedicini, C., Bleasdale, S. C., … & CDC Prevention Epicenters Program. (2019). Personal protective equipment doffing practices of healthcare workers. Journal of Occupational and Environmental Hygiene, 16(8), 575-581. https://doi.org/10.1080/15459624.2019.1628350.
Setting	The study setting is in an acute care hospital of a 465-bed facility. Specifically, the hospital rooms hosting patients with viral respiratory infections are selected as the appropriate sites of the study as one of the hospital locations where healthcare workers interact with patients frequently. The setting was categorized further as intensive care units, non-intensive care units, and special units based in the medical conditions and workflow levels.
Purpose	The purpose of this study was to characterize the utilization of personal protective equipment and doffing practices of healthcare workers caring for viral respiratory infected patients in acute care settings.
Research design	A direct observation study was conducted. A quantitative observation of healthcare workers’ personal protective equipment usage practice before and after attending to patients with viral respiratory infections. The processes that were quantified include the type of personal protective equipment chosen, the donning sequence, caution during running, doffing errors, disposal location, and adherence to hand hygiene.
Sample studied	The inclusion criteria was being of majority age, ability to communicate in English, and caring for patients with viral infections that have consented to participating in the study. Purposive sampling was employed to select the healthcare workers willing to participate in the study through a staff meeting and at the entrances of patients’ wards. A total of 162 observations were made from 107 healthcare professionals attending to 52 infected patients. Some healthcare workers were observed more than once. The participants were categorized into three groups; ‘provider’, ‘nurse’, and ‘others’ groups.
Findings/Results	Correct personal protection equipment were selected by 64% and 57% of the healthcare professionals entering droplet and the combined droplet and contact isolation rooms, respectively. Erroneous persona; protective equipment doffing practices were prevalent among the healthcare workers. Specifically, 97 % of the participants used incorrect personal protective equipment donning practices, with the errors ranging between 88 % and 100 % across different healthcare roles, hospital units and isolation category. Gown doffing errors dominated the erroneous private protective equipment practices. In addition, 50 % and 52 % of the observations recorded touching of contaminated surfaces with bare hands and erroneous removal of personal protective equipment, respectively.
Limitations	The study was limited by being conducted in a single healthcare establishment, which hindered the generalizability of the findings to other healthcare settings. Also, the participants were aware that they were being observed, and therefore, may have changed their behavior. Besides, the study focused on the healthcare professional attending to patients infected with viral respiratory diseases. This limited the generalization of the results to patients with other types of infections.
Level of Evidence and Justification for Level.	The evidence provided by the study is rated at level IV in the hierarchy of evidence. Well-designed cohort studies were conducted. The cohorts were categorized by the hospital units they worked in and the job roles they performed at the healthcare establishment.
Are Findings Valid?	The findings are valid because the intended concepts and variables were measured using the study approach and tools.
Importance of Findings	The findings exposed the nonadherence to the recommendations by the centers for disease control and prevention (CDC) related to the practice of control of healthcare-related infections. They indicated insufficient knowledge and importance of correct personal protective equipment use practices among healthcare workers, reflecting a lack of sufficient education and training.

This study is descriptive with a level VI ranking in evidence hierarchy because it was conducted using a robust design quantitative design, despite not being experimental. It has some extraneous variables beyond the researchers control or that were ignored in the study. For instance, it does not identify the specific reasons behind the erroneous application of personal protective equipment. This study may not provide practice-changing evidence when used in isolation.

Research Article #3

Research Article (provide FULL reference): Carter, B., Collins, J. T., Barlow-Pay, F., Rickard, F., Bruce, E., Verduri, A., … & Stechman, M. J. (2020). Nosocomial COVID-19 infection: examining the risk of mortality. The COPE-Nosocomial study (COVID in Older People). Journal of Hospital Infection, 1-10. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7372282/. https://doi.org/10.1016/j.jhin.2020.07.013.
Setting	Hospitals in the United Kingdom and Italy that treat Covid-19 patients were selected as the setting for the study. Ten hospitals from various locations in the United Kingdom and one hospital in Italy were selected as the appropriate settings for the study. The United Kingdom hospitals were located in Caerphilly, Newport, Abergavenny, Cardiff, Bristol, Aberdeen, paisley, and Glasgow, while the one in Italy was located in Modena.
Purpose	The purpose of this study was to identify the patients that had been infected with Covid-19 while in hospital and compare their risk of death with those that had acquired the viral infection while in the community.
Research design	The researchers claimed that the study was an observational cohort study. The qualitative research used secondary data collected from the personal health records of patients with Covid-19 following a descriptive design. The researchers sought to the median time-to-morality using multivariable analysis.
Sample studied	The sample was drawn from 10 UK hospitals and 1 Italian hospital. The inclusion criteria included being of age equal to or above 18 years and having a clinical Covid-19 diagnosis. The exclusion criteria included the lack of clinical documentation, absence of a clinical diagnosis, and unavailability of data capture clinical resource. A total of 1,564 participants comprising 154 patients from Italy and 1,410 from the united kingdom, were included. Case datasets had a completeness of over 97 %.
Findings/Results	Patients had a median age of 74 years and a mortality rate of 27.2 %, ranging between 12.2 % and 43.9 %. Patients took a median of 32.5 and 0 days between admission and a positive nosocomial and community-acquired Covid-19 infection, respectively. Although the patients with nosocomial and community-acquired Covid-19 infections had a 14 days and 10 days medial time to mortality, respectively, 27.0 % and 27.2 % of patients with nosocomial and community-acquired Covid-19 infection passed on, respectively. Further, the median length of hospital stay was 33 days and 16 days for nosocomial and community-acquired Covid-19 infected patients, respectively. It was influenced by high levels of C-reactive protein, increasing frailty, and ageing. Consequently, nosocomial transmission contributed minimally to covid-19 hospitalization, indicating the effectiveness of infection control measures.
Limitations	The study was limited by its conservative definition of nosocomial Covie-19 infections, which excluded healthcare workers and hospitalized patients’ visitors. In the same vein, mildly symptomatic and asymptomatic patients were not included in the study, thus undermining the determination of face-mix differences between nosocomial and community-acquired Covid-19 infected groups. Moreover, the cause of death among nosocomial and community-acquired Covid-19 infected patients was not analyzed.
Level of Evidence and Justification for Level.	The study represented a level IV strength of evidence in the hierarchy of evidence. It was obtained from well-designed cohort studies. The cohorts were categorized by nosocomial and community-acquired Covid-19 infections, location of infection acquisition, age, gender, and smoking status, presence of underlying conditions, frailty level, and C – reactive protein status.
Are Findings Valid?	The findings are valid because well-established methodologies and scales were employed. These included the currently known Covid-19 incubation periods, estimated glomerular filtration rates (eGFR), and C-reactive protein levels. Therefore, the study adequately measured the key concepts in the study, mainly, the time-to-mortality and length of stay.
Importance of Findings	The importance of the findings is the effectiveness of infection prevention policies and protocols related to highly-infectious disease pandemics.

This study is descriptive with a level VI ranking in evidence hierarchy because it was conducted using a robust design qualitative design that relied on secondary quantitative data, despite not being experimental. It has some extraneous variables beyond the researchers control or that were ignored in the study. For instance, ignoring of some potential spreaders of infections, such as the asymptomatic or mildly symptomatic patients can underrepresent the infection cases. Therefore, this study may not provide practice-changing evidence when used in isolation.

Body of Evidence

The body of evidence presented by the studies ranges is between level IV and VI. Although the studies to not provide high-quality evidence when viewed singly, they can be used collectively to underpin recommendations for clinical practice (Burns, Rohrich, & Chung, 2011). In this regard, the consistency of findings from the three studies provides credence to the proposed intervention. The proposal supported by these studies is the intensive training of nurses regarding infection control and prevention during infectious disease pandemics, especially the correct use of personal protective equipment. This would help reduce nosocomial infections during global pandemics, such as the ongoing Covid-19. However, since information about such infections is still developing, the nursing practitioners should look out for emerging evidence to improve practice further. 

Application to Practice

This practice improvement is appropriate for my unit, which deals with a significant number of patients with highly-infectious diseases. The ramifications of nosocomial Covid-19 are sufficient motivation to overcome any implementation resistance in my unit. However, I will require the support of the administrators, colleagues, and the interdisciplinary medical teams. The director of nursing practice would be the change agent and shepherd of the proposed practice change. 

Evidence-Based Management Using Standardized Guideline

Lewin’s theory for planned change is appropriate in implementing a profession-wide and institution-wide practice change. The three-stage change theory suggests that unfreezing, changing, and refreezing is appropriate for behavioral change that requires a reorientation of existing knowledge and practice (Wagner, et al., 2018). In the unfreezing stage, the need for change in the infection control practice among nurses is identified and supported by evidence. The change stage involves the retraining of nurses on prevention protocols during a pandemic, based on the improved frameworks from the CDC. Proper use of personal protective equipment is taught at this stage. The major impediment to the implementation of the practice change is time and resource scarcity, considering that nurses have a large work load and personal protective equipment are scarce and expensive (Hessels, et al. 2019). In the refreeze stage, the new practice is institutionalized and sustained.

Outcomes

The expected nursing outcomes are a reduction in the nosocomial infections among nurses, and subsequently, a reduction of transmission of the infections to colleagues and patients in the healthcare setting. The success rate of the proper application of personal protective equipment is sufficient motivation to drive the nursing practice change. Emphasis will be on the educating nurses on the choosing the suitable personal protective equipment, and doffing and disposing them appropriately for the nurses’ and patients’ safety.

Summary

Research evidence has demonstrated that hospital-acquired infections continue to challenge healthcare practitioners and place a heavy burden on the healthcare system. Patients that acquire infections while in hospital extend their hospital stays and consume more healthcare resources, which is preventable. The ravages of nosocomial infections have been highlighted by the covid-19 pandemic and exposed the serious health ramifications they portend to the health sector. Nurses can be infected with infectious diseases, which can be passed on to colleagues and patients. The proposed practice change focuses on retraining of nurses on the latest infection control protocols during global pandemics. The risk of nosocomial infections would reduce significantly if the healthcare stakeholders at the hospital adhere to proper choosing, doffing and disposing of personal protective equipment. The current prevalence of improper use of personal protective equipment and gaps in infection control and prevention protocols for pandemic situations can be reversed through evidence-based training support to the healthcare workers.  

Reflection

A global pandemic, such as the ongoing covid-19 presents a scary occurrence, particularly when little is known about the novel infection. Finding robust evidence about a novel disease is challenging and existing control protocols can be insufficient and continuously evolving. However, diligent search for high-quality evidence is critical for advancing evidence-based practice. While such evidence may be difficult to come by, researchers are regularly churning out studies that accumulate such evidence and support nursing practice improvements.

References

Burns, P. B., Rohrich, R. J., & Chung, K. C. (2011). The levels of evidence and their role in evidence-based medicine. Plastic and Reconstructive Surgery, 128(1), 305-310. https://doi.org/10.1097/prs.0b013e318219c171.

Carter, B., Collins, J. T., Barlow-Pay, F., Rickard, F., Bruce, E., Verduri, A., … & Stechman, M. J. (2020). Nosocomial COVID-19 infection: examining the risk of mortality. The COPE-Nosocomial study (COVID in Older People). Journal of Hospital Infection, 1-10. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7372282/. https://doi.org/10.1016/j.jhin.2020.07.013

Chou, R., Dana, T., Buckley, D. I., Selph, S., Fu, R., & Totten, A. M. (2020). Epidemiology of and risk factors for coronavirus infection in health care workers: a living rapid review. Annals of Internal Medicine, 173(2), 120-136.

English, K. M., Langley, J. M., McGeer, A., Hupert, N., Tellier, R., Henry, B., … & Pourbohloul, B. (2018). Contact among healthcare workers in the hospital setting: developing the evidence base for innovative approaches to infection control. BMC Infectious Diseases, 18(1), 1-12. https://doi.org/10.1186/s12879-018-3093-x.

Hessels, A. J., Kelly, A. M., Chen, L., Cohen, B., Zachariah, P., & Larson, E. L. (2019). Impact of infectious exposures and outbreaks on nurse and infection preventionist workload. American Journal of Infection Control, 47(6), 623-627. https://doi.org/10.1016/j.ajic.2019.02.007.

Houghton, C., Meskell, P., Delaney, H., Smalle, M., Glenton, C., Booth, A., … & Biesty, L. M. (2020). Barriers and facilitators to healthcare workers’ adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis. Cochrane Database of Systematic Reviews, (4), 1-71. https://doi.org/10.1002/14651858.cd013582.

Phan, L. T., Maita, D., Mortiz, D. C., Weber, R., Fritzen-Pedicini, C., Bleasdale, S. C., … & CDC Prevention Epicenters Program. (2019). Personal protective equipment doffing practices of healthcare workers. Journal of Occupational and Environmental Hygiene, 16(8), 575-581. https://doi.org/10.1080/15459624.2019.1628350.

Wagner, J., Willcox, A., Sutherland Boal, A., de Padua, A., Balaski, B., Ens, B., Toye, C. R., … & MacPhee, M. (2018). Leadership and Influencing Change in Nursing. University of Regina Press.