NSG 502 -Alcohol-Based Hand Rubs in Reducing Hospital-Acquired Infections essay

Evidence-Based Systematic Review

The Impact of Alcohol-Based Hand Rubs in Reducing Hospital-Acquired Infections in an Acute Setting Care

Introduction

Hand hygiene is an important practice that has been used to prevent healthcare-associated infections (HAIs). The World Health Organization (WHO) recommends the use of alcohol-based hand rubs over the normal hand-washing using water and soap. This is because alcohol-based hand rubs have broad microbial spectrum, better skin tolerance, easily available at the point of care, and time efficiency (Luangasanatip et al., 2015). In addition, alcohol-hand rubs increase adherence to hand hygiene among healthcare workers. The rate of HAIs is very high and the HAIs are associated with adverse outcomes such as increased mortality rate, increased morbidity, the increased period of hospital stay, as well as increased healthcare costs (Jia et al., 2019). Therefore, the aim of systematic review is to examine the evidence for alcohol-hand rubs in effectively decreasing the microbial load on the hands and being an effective hand-hygiene technique in preventing HAIs. NSG 502 -Alcohol-Based Hand Rubs in Reducing Hospital-Acquired Infections essay

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PICOT Question

In patients hospitalized in acute care settings (P), does use of alcohol-based hands rubs (I) compared to handwashing with soap and water (C) lower the rate of hospital-acquired infections (O) within 3 months (T)?

Purpose or Aim of the Review

Hand hygiene is the most effective measure to prevent infections (Luangasanatip et al., 2015). Even though hand-hygiene is a simple process and its efficacy in preventing infections in hospital settings has been demonstrated, adherence to hand hygiene is not consistent. There are different techniques of hand hygiene and the adherence and efficacy of the hand hygiene techniques differ. This systematic review, therefore, aims to examine the evidence for alcohol-hand rubs in effectively decreasing the microbial load on the hands and being an effective hand-hygiene technique in preventing HAIs.

Methodology

Literature Search Criteria and Strategies

A set of inclusion and exclusion criteria were used when performing this systematic review. First, this systematic review focused on exploring the relationship between alcohol-based hand rubs and hospital-acquired infections. The second criterion was that studies chosen for this systematic review were published within peer-reviewed journals to validate their quality. Thirdly, all included studies were published in the last 5 years (2014 or after). Lastly, the studies had to be published using the English language to allow the researcher to comprehend their content.

Search Strategy
A detailed search of systematic bibliography was conducted to identify research studies relevant for this systematic review. The search was performed on various databases available online and included databases such as CINAHL, PubMed, Web of Science, and Wiley library. This was performed to adequate locate and identify the relevant high-quality studies to be used for this study (Grewal et al, 2016). The reference lists of all the retrieved studies were also analyzed and any study that was found to be relevant and met the inclusion criteria was searched and identified. The search was conducted independently by the research NSG 502 -Alcohol-Based Hand Rubs in Reducing Hospital-Acquired Infections essay. the search was conducted by breaking the PICO (Population, Intervention, Comparison, and Outcome) into various search terms. PICO is a technique utilized in evidence-based practice in framing and answering clinical questions as well as in designing literature search strategies (Eldawlatly et al, 2018). The PICO question for this systematic review was: In patients hospitalized in an acute care setting (P), does use of alcohol-based hands rubs (I) compared to handwashing with soap and water (C) lower the rate of hospital-acquired infections (O) within 3 months (T)? The table below provides a summary of the results of the search using PICO terms

PICO Search Term in this Systematic Review

Search terms Number of articles
Alcohol-based hands rub 500
Handwashing with soap and water 654
Hospital-acquired infections 406
Alcohol-based hands rub and Hospital-acquired infections 325
Handwashing and Hospital-acquired infections 285

Comprehensive Search and Results

Identification of literature requires in-depth searching and location of different sources, including the bibliographic databases. For this systematic review, the unlimited search produced a total of 10,200 research studies published using English language. After the removal of the duplicates and scrutiny of the titles for the relevance, 10, 000 were excluded and therefore 200 articles remained. These studies were excluded because they were not relevant to the study topic. The titles and the abstracts of the selected articles were scrutinized and a further 110 articles were eliminated, and this left a total of 90 articles. Further scrutiny was done basing on the inclusion criteria and this led to the exclusion of 65 articles. This left a total of 25 articles. The remaining 25 articles were critical analysis for quality using CASP tools and finally, only 6 research articles fulfilled all the set inclusion criteria. NSG 502 -Alcohol-Based Hand Rubs in Reducing Hospital-Acquired Infections essay

Critical Appraisal Process and Findings

The critical appraisal process involved systematically evaluating the selected articles for this systematic review according to the set inclusion and exclusion criteria. The tool used to critically appraise the articles was the CASP tool. Critical appraisal is very important in systematic reviews to ensure that the evidence is integrated robustly. This was performed to ensure the reliability, accuracy, and validity of the selected studies Research articles that critically appraised and established to be adequate as per the CASP tool were chosen for this systematic review.

Findings

In stage 1, a total of 10,200 bibliographic records were identified via the database search. Duplicates were removed and titles scrutinized for the relevance and 10, 000 were excluded and therefore 200 articles remained. These studies were excluded because they were not relevant to the study topic as they did not cover healthcare-associated infections or hand hygiene techniques. The titles and the abstracts of the selected articles were scrutinized and a further 110 articles were eliminated, and this left a total of 90 articles. Further scrutiny was done basing on the inclusion criteria and this led to the exclusion of 65 articles. This left a total of 25 articles and after the critical appraisal, only 6 articles were included for this systematic review. The following table represents the tabular representation of the findings.

Tabular presentation of all included studies

Author/s (year) Main Study Characteristics Aim of the Study Interventions Main Findings

  1. Chatfield, S. et al (2016) United States
    Qualitative study

In-depth interviews

8 nurses

To find out the impact of improved hand hygiene among acute care nurses on healthcare-associated infections Hand-washing with soap & water
Alcohol-based hand rubs

There is a correlation between hand-hygiene practices and healthcare-associated infections
Adherence to hand hygiene among nurses is low

  1. Chavali, S., et al (2014) USA
    The tertiary level multispecialty hospital

Cross-sectional, surgical ICU

Observational study

28 nurses & 10 allied healthcare workers

To examine the adherence to hand hygiene among nurses & associated healthcare workers after training in proper hand hygiene WHO 6-step technique
Alcohol-based hand rubs

Hand-washing

NSG 502 -Alcohol-Based Hand Rubs in Reducing Hospital-Acquired Infections essay

The training led to increased adherence to hand-hygiene and also there was a significant reduction of health-care-associated infections

  1. Keller, J., et al (2018)

Switzerland
University Hospital Zurich

Emergency department

Mixed-method quasi-experimental

Questionnaires

Semi-structured interviews
Different healthcare practitioners

To investigate the adherence to hand-hygiene, consumption of alcohol-based hand rubs, and the perspective of healthcare workers about wearable dispensers

Wearable dispensers for alcohol-based hand rubs The wearable dispensers did not increase adherence to hand hygiene compliance or the consumption of alcohol-based hand rubs

  1. Oliveira, A et al (2017) Brazil
    Tertiary university hospital

Cross-sectional study

Data collected through observation and questionnaire

46 nurses

To determine the adherence rate & related factors to acceptance of alcohol-based hand rubs when compared to hands antiseptic friction for nurses in an intensive therapy unit Alcohol-based hand rubs
Hands antiseptic friction

There was low adherence to alcohol-based hand rubs as nurses preferred hand washing using soap and water. Alcohol-based hand rubs are associated with easy access, efficacy in eradicating microorganisms and also, they do not cause skin dryness and irritation. Therefore, there is a need to educate nurses about the advantages associated

  1. Price, H et al (2018) Systematic review
    Types of studies included randomized controlled trials (RCTs), non-randomized controlled trials, case-control studies, observational/descriptive studies & cohort studies

Databases used included Medline, CINAHL, Web of Knowledge & Proquest

To evaluate the evidence for the alcohol-based hand rubs and WHO technique in decreased the microbial-load on the hands of healthcare providers WHO 6-step technique (hand rubbing with alcohol utilizing the WHO technique WHO technique is effective in preventing HAI
The most effective hand hygiene technique was not identified

NSG 502 -Alcohol-Based Hand Rubs in Reducing Hospital-Acquired Infections essay

  1. Saito, H et al (2017) Uganda;
    Mbale Regional Referral Hospital;

1 hospital:

Quasi-experimental study

Primary data;

Self-administered questionnaire;

Nurses

To examine the hand hygiene practices of healthcare providers using alcohol-based hand rubs and the incidence of hospital-acquired infections Alcohol-based hand rubs

Use and adherence to hand hygiene was associated with a significant decrease to the hospital-acquired infections in the surgical and pediatric departments

Discussion of Findings

Findings from all studies indicated that effective hand hygiene is the key to reducing the risk of hospital-acquired infections. According to Chavali et al (2014), whereas either effective hand-washing using soap and water or effective use of alcohol-based hand rubs removes transient microbes, alcohol-based hand rubs significantly reduces resident microorganisms. This is supported by Price et al (2018) supported by who explain that alcohol-based hand rubs have a higher likelihood of killing microorganisms when compared to handwashing. The study by Saito et al (2017) indicated that adherence to hand hygiene was associated with a significant decrease in HAIs. The study by Oliveira et al (2017) demonstrated that alcohol-based hand rubs have a significant impact on reducing HAIs. Therefore, because of the increased effectiveness and easy availability of alcohol-based hand rubs at the point of care, they are highly accepted and this can be attributed to the reduced incidence of HAIs when alcohol-based hand rubs are used. However, the findings of Keller et al (2018) showed that adherence to hand-hygiene did not increase when alcohol-based hand rubs were used. NSG 502 -Alcohol-Based Hand Rubs in Reducing Hospital-Acquired Infections essay

Implications

This review provides evidence that supports the use of alcohol-based hand rubs in clinical practice. This is because there is increased adherence to hand hygiene when alcohol-based hand rubs are used in comparison to hand-washing using water and soap: this is attributable to the reduced rate of HAIs in hospital settings. Therefore, in case there is no visible dirt on the hand, the use of alcohol-based hand rubs is the recommended hand-hygiene technique. However, when it is visible, handwashing using water and soap is recommended. It is important to educate nurses on the importance of adhering to hand hygiene practices to reduce the rate of HAIs.

Limitations

Limitations associated with this systematic review include that it was performed by one researcher and this might have introduced some bias. Quality assessment and appraisal of systematic reviews should be performed by over one independent reviewer. Additionally, only studies published using English language were included which might have restricted other high-quality studies conducted using a different language. Lastly, study participants in the chosen articles contained different demographics that complicated collation and interpretation of the findings. Because of these limitations, generalizing the findings from this review ought to be done cautiously.

Conclusion

Effective infection control is the key to preventing HAIs. Hand hygiene is effective in decreasing the rate and preventing HAIs. Evidence from this systematic review suggests that adherence to hand hygiene is higher when alcohol-based hand rubs are used as the hand hygiene technique. This is the reason the use of alcohol-based hand rubs is associated with a reduced rate of HAIs. Therefore, healthcare organizations should implement the use of alcohol-based hand rubs as a strategy towards preventing and reducing HAIs. NSG 502 -Alcohol-Based Hand Rubs in Reducing Hospital-Acquired Infections essay

References

Chatfield, S. L., Nolan, R., Crawford, H., & Hallam, J. S. (2016). Experiences of hand hygiene among acute care nurses: An interpretative phenomenological analysis. SAGE open medicine, 4, 2050312116675098. https://doi.org/10.1177/2050312116675098.

Chavali, S., Menon, V., & Shukla, U. (2014). Hand hygiene compliance among healthcare workers in an accredited tertiary care hospital. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 18(10), 689–693. https://doi.org/10.4103/0972-5229.142179.

Eldawlatly, A., Hussain, A., Ahmed, A. and Amir, M. (2018). The appearance of Population, Intervention, Comparison, and Outcome as a research question in the title of articles of three different anesthesia journals: A pilot study. Saudi J Anaesth,12(2), pp.283–286.

Grewal, A., Kataria, H., and Ira, D. (2016). A literature search for research planning and identification of research problem, Indian J Anaesth, 60(9), pp.635–639.

Jia, H., Li, L., Li, W., Hou, T., Ma, H., Yang, Y., & Luo, X. (2019). Impact of healthcare-associated infections on length of stay: a study in 68 hospitals in China. BioMed research international, 2019.

Keller, J., Wolfensberger, A., Clack, L., Kuster, S. P., Dunic, M., Eis, D., … & Sax, H. (2018). Do wearable alcohol-based hand rub dispensers increase hand hygiene compliance? -a mixed-methods study. Antimicrobial Resistance & Infection Control, 7(1), 143.

Luangasanatip, N., Hongsuwan, M., Limmathurotsakul, D., Lubell, Y., Lee, A. S., Harbarth, S., … & Cooper, B. S. (2015). Comparative efficacy of interventions to promote hand hygiene in hospitals: a systematic review and network meta-analysis. BMJ, 351, h3728.

Oliveira, A. C. D., Gama, C. S., & Paula, A. O. D. (2017). Adherence and factors related to acceptance of alcohol for antiseptic hand rubbing among nursing professionals. Revista da Escola de Enfermagem da USP, 1(51).

Price, L., Melone, L., McLarnon, N., Bunyan, D., Kilpatrick, C., Flowers, P., & Reilly, J. (2018). A systematic review to evaluate the evidence base for the World Health Organization’s adopted hand hygiene technique for reducing the microbial load on the hands of healthcare workers. American journal of infection control, 46(7), 814-823.

Saito, H., Inoue, K., Ditai, J., Wanume, B., Abeso, J., Balyejussa, J., & Weeks, A. (2017). Alcohol-based hand rub and incidence of healthcare-associated infections in a rural regional referral and teaching hospital in Uganda (‘WardGel’ study). Antimicrobial resistance and infection control, 6, 129. https://doi.org/10.1186/s13756-017-0287-8

Students are to select option 1 or 2 and read the corresponding chapters. The writing rubric will be used to grade the final paper. Follow closely the Grading Rubric for Written Assignment found in the Course Resources section of the course. Be sure to include an Introduction and Conclusion to the assignment. This is a formal paper. Follow APA 6th edition format. The paper should be no more than 10 pages, excluding the title and reference pages. An abstract is not required for Choice 1. NSG 502 -Alcohol-Based Hand Rubs in Reducing Hospital-Acquired Infections essay

Choice 1: Quantitative or Qualitative Research Proposal

Choose a topic of interest and write a proposal to a funding agency. The proposal must include the problem, purpose, significance, feasibility, literature review, framework, design, sample, measurement, and plan for collection and analysis of data. A study budget and timetable should also be included. (Refer to Chapters 28 and 29 of the required course textbook.)

Components:

Title page
Introduction
Literature review
Framework
Research Hypotheses/questions
Methodology
Plans for Data Collection and Analysis
Budget
Conclusion
Appendices, as appropriate
Choice 2: Evidence-Based Systematic Review

Identify a clinical problem and develop a PICO question. Review the literature about this question, using a minimum of 10 references. This systematic review will identify, appraise, and synthesize the studies to answer the question. Conclusions are made based on scientific evidence. (Refer to Chapter 19) NSG 502 -Alcohol-Based Hand Rubs in Reducing Hospital-Acquired Infections essay

Components:

Title Page
Abstract
Introduction
Relevant PICO clinical question
Purpose or aim of review
Literature Search criteria and strategies
Comprehensive search and results
Critical appraisal process and findings
Results of findings (table and narrative format)
Discussion of findings—implications, limitations, conclusions
Conclusion
Qualitative Critique Rubic

Excellent Good Acceptable Unacceptable
Title (3 points) Does the title represent the focus of the study? 3 2 1 0 /3
Abstract (3 points) Does the abstract summarize the purpose of the study, qualitative approach, sample and key findings? 3 2 1 0 /3
Research Problem (5 points) What is the phenomenon of interest? Is it explicit? Significance to the researcher noted? To nursing? 5 4 3 1 /5
Purpose and Research Questions (5 points) Clearly stated? Logical approach to addressing the research problem of study? Are there explicit questions? Consistent with framework? Method appropriate to answer research questions? 5 4 3 1 /5
Literature Review (4 points) References current? Reviews previous studies and theories? Critically appraises and synthesizes the studies? Summarizes what is known and not known? 4 3 2 1 /4
Philosophical Foundation/Theoretical Perspective (5 points) Philosophical theory and perspective described? 5 4 3 1 /5
Research Design (5 points) Is the design appropriate? Describe the perspective and state if researcher was true to the design. 5 4 3 1 /5
Sample and Setting (5 points) What sampling method was used? Is it appropriate? Was sample described? How were participants recruited? Was inclusion/exclusion criteria described? Role of researcher in sampling process? NSG 502 -Alcohol-Based Hand Rubs in Reducing Hospital-Acquired Infections essay 5 4 3 1 /5
Data Collection (20 points) Process clearly described? Conducted in a consistent manner? Any adverse events and were they managed well? Information on potential risk and benefits? 20 16 12 5 /20
Data Analysis and Methodological Congruence (20 points) Discuss rigor and threats to the qualitative process. Make sure to address all aspects of rigor evaluation. What type of thematic analysis process for coding data based on the design methodology? Themes and concepts clearly described? Heuristic relevance? 20 16 12 5 /20
Discussion (6 points) Interpretation and Implications for future research 6 5 3 1 /6
Evaluation (4 points) Strengths? Weaknesses? How the study contributes to nursing knowledge 4 3 2 1 /4
APA, Grammar, Spelling, Constructive Writing (15 points) NSG 502 -Alcohol-Based Hand Rubs in Reducing Hospital-Acquired Infections essay

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