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Hand Hygiene (HH) or hand washing in hospital must improve in order to reach zero mortality, shorter patient stays and lower costs for patients and their families. A meta-analysis was carried out to collect studies with a common methodology so that the results can be evaluated with statistical analysis. Searches on the PubMed database were used to identify articles addressing both the issue of hand hygiene and paediatric hospitals. Several searches were carried out until the number of articles for the study was narrowed down to five peer-reviewed academic articles. The number of total HH opportunities and positive HH activities were reported for nurses, physicians and staff in four of the studies. The fifth study reported the total HH opportunities and positive HH activities on 2003 and 2006. From the information available the percentage of HH opportunities was calculated. A portion of the results were used to calculate Relative Risk Confidence, Confidence level of risk ratio, relative risk, 95% Confidence Level, Need-to-Harm, and multiple probabilities. A database from the data collected was created on Excel to organize and evaluate the results from the studies. The overall evaluation of the results the five studies demonstrated that HH can be successfully and effectively improved given the appropriate interventions. (206 words)
(Key words: hand hygiene, children’s hospitals, paediatric hospitals, statistical analysis, HAIS)
Hand hygiene is a cause of the hospital acquired infections (HAIS) also known as nosocomial infection occurring in hospital environments. The infections may be acquired in the patient population or by the staff. The physicians, nurses and staff can all wash their hands more often in order to accomplish all those improvements. The problem of HAIS affects a large number of people worldwide. Over a million people around the world become infected while in the hospital with Hospital Acquired Infections (HAIS) (Gill, 2014). The illnesses associated with HAIS affect patients, staff and health care providers. The World Health Organization (WHO) and other organizations are cooperating programmes to educate and train hospitals how to enhance HH.
Research studies are carried out in order to track improvements after interventions, training, education and other methods have been applied. Observations are made before the research activity is introduced so that pre- and post-intervention values can be evaluated. The comparison of methodologies for statistical analysis varied from study to study but a few common measurements were identified. The results of statistical analysis in the published academic articles or calculated by the researcher included the following: relative risk confidence, confidence level of risk ratio, relative risk, 95% Confidence Level, Need-to-Harm, and multiple probability.
PubMed database was used to search for appropriate articles; the details are reported in the section titled ‘Strategic Search.’ We will perform a meta-analysis of peer reviewed articles available in PubMed. A search was also carried out on Science Direct. The key search words used were hand hygiene, hospital acquired infections, children’s hospitals and compliance with hand hygiene. Included will be articles published in the last 10 years, with the outcomes measured primarily, but not limited to improved quality. Included will be cohort studies and randomized control trials (if any) in US hospitals, on adult patients. Excluded will be indirect transmission of infections, airborne and fecal-oral infections.
A meta-analysis of academic peer-reviewed articles Risk of Outcome, Absolute Risk Reduction, Relative Risk and Number Needed-to-Treat are calculated for the data reported by Medeiros, Grinberg, Rosenthal, and Angelieri (et al. 2015). The researcher calculated relative risk confidence, confidence level of risk ratio, relative risk, 95% Confidence Level, Need-to-Harm, and multiple probability by applying on-line calculators located at Easy Calculation and a calculator at the Medical University of Cincinnati. Five articles were evaluated and the results were collected and organized into a database.
The first search was carried out on PubMed using only the three search phrases hand hygiene, hospital acquired infections, children, paediatrics. The search resulted in 16 articles. The articles were not well-focused. The search resulted in a range of studies with HAI as the common denominator. The next search was carried out with fewer words. The second search was carried out on PubMed with the search words hand hygiene, paediatric hospital. The search resulted in 126 articles. The first 60 articles in the search were the most relevant and the most up-to-date. The articles about children’s hospitals in other countries were discarded, so were articles that were not directly to the health of patients, or did not have reference to hand hygiene and children in the title. The articles dealing with hand washing at child care centre were also discarded.
Another search was carried out on the ScienceDirect database site using the search words hand hygiene, paediatric hospital. That search resulted in 8,922 papers. ScienceDirect allows a user to refine a search by year, publication title, topic, and content type (journals, books, or reference work). Nevertheless, the PubMed site is excellent for a focused search. After establishing the choices the user prefers, PubMed suggests titles that might be suitable. The PubMed site is easy to use and allows finding papers on a focused subject efficiently. The significant factor is using suitable key words. Finally, five articles were collected from the original search of approximately 40 papers.
The first round for the search resulted in four articles. (See table 1) Several attributes were identified the following topics in common: hospital setting, hand hygiene, children, and illness in the form of infections. The measurements and the statistics varied from study to study.
Another method applies was to compare the key words for a set of four articles from the above table. (See table ) None of the key words were exactly matched. (See table 2)
A second search was undertaken on PubMed. Five new articles were identified by comparing the information in each of the abstracts. (See table 3) Seven articles were identified and several features were organized in table three to assess the similarities and differences. The seven articles were first assigned identification labels from ID-A to ID-F. The top row of the table lists the following topics Hand Hygiene Opportunities, Overall Adherence, Analysis, Increased Adherence, and Antibiotic Gel Compliance.
The type of infections addressed in the HH research for two studies were the infections Rotavirus gastroenteritis (RVGE) and Methicillin-resistant Staphylococcus aureus (MSRA). The statistical analyses varied but the Preventive Fraction for Exposure was reported for paediatric hospitals in all of the articles.
Five peer reviewed papers were chosen in the last search the list of the identification label, the first author and a shortened tile are listed in table 4. ID-A (Medieiros. Grinberg, Rosenthal, and Angelieri (et al. 2015: 10) describes HH as the “main tool for cross-infection prevent.” The study took place in four intensive care units (ICU) in four hospitals located in three cities in Brazil. The research is focused on HH and nosocomial infections. Medieros (et al. 2015) used a multi-faceted research method with a foundation of observation of hand washing practices and then applying interventions. ID-B
(Scheithauer, Oude-Aost, Heimann, and Haefner (et al. 2010) focused their research on HH in paediatric and neonatal intensive care (NICO). The researchers observed hand washing practices based on the job positions of the personnel in the unit. The research agreed that HH is the “single most effective tool to prevent health care-associated infections” (Scheithauer et al. 2010: 732). HH was dependent on the shift of the employees (day or night). Nurses met compliance at the highest level and when and where most needed. The use of antibiotic gels was introduced with a method on how to calculate compliance by calculating the amount of gel used.
ID-D Song, Stockwell, Floyd and Short ( et al. 201) demonstrated that as HH compliance increased the rate of nosocomial rotavirus gastroenteritis (RVGE) decreased; a correlation was identified. ID-E Buet, Cohen, Marine, and Scully (et al. 2013) observed HH opportunities in a four paediatric extended care facilities. The research took into account handwashing before and after touching a patient, the environment near the patient, after the exposure to body risks and before using aseptic cleansing. The study determined that a concerted effort needs to be made to take advantage of all the HH opportunities. ID-F by Waisbourd-Zinman, ben-Ziony, Solter, and Chodick (et al. 2011) target nosocomial related RVGE compared to total hospitalizations for RVGE and considered the relationship of the infection with HH. After intervention the amount of HH increased and the number of RVGE infections identified decreased.
Statistical analysis was carried out to determine risk compared to a control. The change of an adverse event taking place is termed a ‘Risk.’
The relative risk calculation (RRC) for nurses in study ID-A equalled approximately 1 (0.9909) showing that nurses reliably and continuously were practicing HH. The physicians observed in the study were calculated to have a -0.497 RRC. The two calculations are difficult to validate because the research did not report a control group. Therefore, a 50:50 chance that all individuals would either show a positive or negative HH opportunity. According to that reasoning the total for nurses 738 and the total for doctors 572 were used as controls to calculate RRC.
Another attempt to estimate a control was to assume that 50% of the total is expected to be positive and 50% is expected to be negative for the control. The method was applied to the data reported in ID-D. The overall improvement for doctors was calculated to be 1.7835 RRC and 0.3523 for nurses. The researcher recommends that this method is better than the method above for calculation of RRC for control. The RRC reflected the findings in the studies that the risk factor for infections is less from nurses due to their HH practices. (See table 5)
For the research reported in ID-D statistics were calculated using an online Relative Risk Reduction Calculator and Risk Reduction Calculators to determine the probabilities of outcomes under controlled and experimental circumstances. The absolute benefit reduction was calculated to be approximately 89% with a 95% Confidence Level at [39%, 41%]. The number of need to harm was calculated to be 2.6 [95% CL: 2.4, 2.7]. The 2.6 patients treated with new HH practices are equal to one adverse event if the circumstances had been equal to the control (assumed to be 100% compliance). The base case was calculated to find that the absolute risk increase was 39% of the patients will experience adverse events with new HH changes that would not be experienced under control. The control was assumed to guarantee 100% compliance with HH practices. For intervention after patient contact, the calculations yielded about 32% [95% CL: 21%, 34] with number needed to harm equalling 3.1.
Calculation of Effect Estimates
The probability for possible treatment outcomes and the case of multiple event probability were calculated using the online calculator and by considering the results from ID-A. High HH practices adoption is higher for nurses. (See table 6) Seven hundred thirty eight opportunities were identified and the HH opportunities could result in hand washing or no hand washing. Table 6 shows that nurses have a higher probability of hand washing than the physicians. (Five hundred seventy two is the number of possible outcomes observed for physicians in the ID-A study.) The probability that either hand washing or no hand washing will occur for both nurses and physicians is about 0.75 (See column nine in table 6)
Preventive Fraction for Exposure
Calculation of Effect Estimates is the most common and practical way to address data for HH. (See table 5) Four out of the five studies reported data for HH opportunities by observing nurses and physicians. The calculation was based on Negative HH opportunities (high HH)/Total HH opportunities multiplied by 100 in order to compute percentages. The data from ID-A, ID-D, ID-E and ID-5 was transformed into percentage. The percent use for nurses of HH was 55% total, 49%, 64% and 57% in paediatric units and 66% in neonatal units. ID-D reported an overall 82% improvement for nurses after introducing strategies to increase HH. The physicians on the other hand were consistently lower than the nurses. For ID-a reported 52% total, ID-D reported 59%, ID-E 67% (the only identified data showing physician higher than nurses; the amount of difference is 3%). Meanwhile, the data from ID-B demonstrate that physicians used HH 29% of the time in the paediatric units and 52% in the neonatal facility.
Nurses consistently showed more improvement than physicians. In the two studies were HH was correlated with illness, the illness events decreased, as the HH practices increased. Therefore, the research indicates that the global programmes to reduce illness due to poor HH can be effective. The research recommends that future studies that use statistical analysis must report very clearly the control the researchers assumed so that probabilities can be more reliably calculated. Future studies that are designed to make observations, develop appropriate interventions, and then measure the effectiveness of the interventions are highly needed. The attention brought to the topic of HH in the hospital environments reviewed in the study, resulted in increasing awareness of the need to integrate HH practices into every unit of hospitals. The hospital staff needs to acquire HH habits, and so do patients, their parents and their visitors. The reduction of infections associated with increased HH practices demonstrates a direct correlation.
Buet, Amanda, Bohen, Bevin, Marine, Melissa, Scully, Fiona, Alper, P., Simpser E, Saiman L, and Larson E. “Hand hygiene opportunities in pediatric extended care facilities.” J Pediatr Nurse 2013 Jan;28(1):72-6. Epub 2012 Jun 1. Web. 22 February 2015. doi: 10.1016/j.pedn.2012.04.010.
Cloutman-Green, Elaine , Kalaycioglu, Oya Hedieh Wojani, John C. Hartley, Serge Guillas, Deirdre Malone, Vanya Gant, Colin Grey, and Nigel Klein. “The important role of sink location in handwashing compliance and microbial sink contamination.” American Journal of Infection Control, 42.5, (2014)” 554-555. Web. 22 February 2015 http://dx.doi.org/10.1016/j.ajic.2013.12.020. Web. 22 February 2015.
Easy Calculations. https://www.easycalculation.com/statistics/relative-risk.php
Medeiros EA, Grinberg G, Rosenthal VD, Bicudo Angelieri D, Buchner Ferreira I, Bauer Cechinel R, Zanandrea BB, Rohnkohl C, Regalin M, Spessatto JL, Scope, Pasini R, and Ferla S. “Impact of the International Nosocomial Infection ControlConsortium (INICC) multidimensional hand hygiene approach in 3 cities in Brazil.” Am J Infect Control. 2015 Jan; 43(1):10-5. doi: 10.1016/j.ajic. 2014.10.001. Web. 22 February 2015
Risk Calculator http://araw.mede.uic.edu/cgi-bin/nntcalc.pl Web. 22 February 2015.
Song X, Stockwell DC, Floyd T, Short BL, and Singh N. “Improving hand hygiene compliance in health care workers: Strategies and impact on patient outcomes.” Am J Infect Control. 2013 Oct; 41(10):e101-5. doi: 10.1016/j.ajic.2013.01.031. 2013 May 2. Web. 22 February 2015
Waisbourd-Zinman, Orith, Ben-Ziony, Shiri Ester Solter, Gabriel Chodick, Shai Ashkenazi, and Gilat Livni. “The percentage of nosocomial-related out of total hospitalizations for rotavirus gastroenteritis and its association with hand hygiene compliance.” American Journal of Infection Control, 39.2, (2011): 166-168. Web. 22 February 2015 http://dx.doi.org/10.1016/j.ajic.2010.06.008.
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