Recommending an evidence-based practice change

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Evaluation Table

Use this document to complete the evaluation table requirement of the Module 4 Assessment, Evidence-Based Project, Part 4A: Critical Appraisal of Research

Full APA formatted citation of selected article.

Article #1 Article #2 Article #3 Article #4 Kritsotakis, E. I., Kontopidou, F., Astrinaki, E., Roumbelaki, M., Ioannidou, E., & Gikas, A. (2017). Prevalence, incidence burden, and clinical impact of healthcare-associated infections and antimicrobial resistance: a national prevalent cohort study in acute care hospitals in Greece. Infection and drug resistance, 10, 317–328. https://doi.org/10.2147/IDR.S147459

Kampiatu, P., & Cozean, J. (2015). A controlled, crossover study of a persistent antiseptic to reduce hospital-acquired infection. African journal of infectiousdiseases, 9(1),69.https: //doi.org/10.4314/ajid.v9i1.2

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

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/10.1177/2050312116 675098

Evidence Level * (I, II, or III)

This study is level III evidence because it is a cohort study and cohort studies are not randomized.

This is Level III evidence because it is a controlled clinical study without randomization.

This study is a Levell III evidence. This is because the study is a controlled clinical trial without randomization. This study applied the crossover design where the same group of participant serves as both the experimental and the control group

This study is a level III evidenced because it is a qualitative studies seeking opinions and perceptions.

Critical Appraisal Tool Worksheet Template

https://doi.org/10.4314/ajid.v

and the participants were not randomly selected.

Conceptual Framework

Describe the theoretical basis for the study (If there is not one mentioned in the article, say that here).**

Not discussed in the study Not discussed in the study Not discussed in the study Not discussed in the study

Design/ Method

Describe the design and how the study was carried out (In detail, including inclusion/excl usion criteria).

This study is a prevalent cohort study. A total of 8,247 participants were recruited from all the acute care hospitals in Greece representing a national cross-section of the entire patient admitted acute care hospital all over the country in one day. A purposive sampling was used in selecting the participating hospitals. There are three inclusion criteria for selection and they includes: one district referral hospital from each of the regional health district in Greece , four General hospital from every district and the hospital must have a functional infection control team. A total of 37

The study employed a crossover design in finding the ability of a novel hand sanitizer that with a persistent antimicrobial efficacy in reducing the rate of infection in a hospital setting. The study was carried out over a period of three months in three wards of a tertiary hospital. The first and the third months served as the controls and hand washing techniques were used while the novel alcohol based hand sanitizer was introduced in the three wards allowing for comparison. This research, being a crossover study, allows each of the wards to

The study is a quasi-experimental study with the aim of comparing the rate of incidence of healthcare associated infection (HAIs) before and after the introduction of alcohol base hand sanitizer. Five wards were selected from three departments. In pediatric department, acute and general pediatric ward was selected. The gynecological and post –natal ward were selected for obstetrics and gynecology department while general surgical ward was used for surgical department. The study was conducted within 24 months. 12 week was pre- intervention period when the units are

This study is a qualitative research and employed an in-depth individual interview for it data collection. Eight nurses that were employed at different hospital in the United States were selected by the research screening organization and interviewed for this study. To be eligible for selection, the nurse is required to speak and understands English language enough to understand and respond fluently to interview questions. Secondly the participant must be actively employed in a fulltime position in an acute care hospital and must be

acute care hospitals were selected throughout Greece. For patient to meet the criteria for selection, the patient must be admitted to an acute ward on or before 8 AM and should remain on the ward at the of baseline survey. Patients who happened to be day case are exempted. Data was collected by 115 infection control specialist through active recording of active HAIs and the associated length of stay of the affected patients.

serve as its own control. Medical professionals included in the study are those that have direct contact with patient while those that do not have a direct contact with the patients are excluded. Each health professionals entering the three wards are expected to perform their activities depending on the period of the studies.

1. Wash hands following the standard protocol during the control months

2. Apply alcohol based hand sanitizer following the instructions on the bottle as part of the treatment during the treatment month.

using the standard hand hygiene and another 12 week was the intervention period when the alcohol hand sanitizer is introduced. Inclusion criteria for the study were all the patients who were admitted on the selected wards during the study. Data was collected using research assistants. The data collected was reviewed by the research supervisor and then entered into an Epi Info data base.

having a direct patient care. An interview guide was made using the IPA framework and was amended to elicit answers concerning the topic of interest. The audio of the conducted interviews were recorded and professionally transcribed.

Sample/ Setting The number and characteristics of patients, attrition rate, etc.

Purposive sampling was use in selecting a total of 37 acute care hospitals that meet the selection criteria. These selected hospitals comprises of 27% of all public hospitals in Greece. The hospitals had a total of 16,164 beds which represents 46% of total hospital beds in Greece. A total of 8,247 patients were selected from the 37 selected

The research was carried out at Kikuyu Hospital, one of the foremost private tertiary hospitals in East Africa. For the study the men's Ward, the Women's Ward, and the Eye Care Ward were selected. The healthcare professionals working in these three wards were separate with minimal interactions. A total of 36 nurses participated in the study and 6000 patient days were recorded during

The study was conducted at Mbale Regional Referral Hospital (MRRH), a government tertiary hospital in eastern Uganda. The hospital has is made up of 12 wards with a total of 550 beds. The hospital serves over four million 550 in 15 local district. The hospital is also a teaching hospital for 40 physicians and 170 nurses and student. During the period of study .there were 12,665 admissions across the selected wards from which a total

The study was conducted in the United States of America with eight participating nurses drawn from different part of the country. The selected nurse’s represents, Neo-natal ward (2 nurses) Labor and delivery; triage, intravenous team and a general care nurse all have one each. An additional two nurses with supervisory roles from

hospitals the acute the studies. of 3335 patients (26.3%) were enrolled into the study. The study excluded those pt who were admitted in study weeks 12 and 13.

oncology and pediatrics were added. These selected nurse have between 6 to 28 years of experience in the field of nursing.

Major Variables Studied

List and define dependent and independent variables

Independent variable is infection control. This is because infection control can cause a change in the incidence of HAI in Greece Dependent variables are: annual incidence of HAIs . This is a dependent variable because outcome is dependent on infection control the incidence of HAIs may be high or law depending on the level of infection control.

There are two independent variables in this study they are : Hand washing using the standard protocol and the use of the alcohol based hand sanitizer. These are the independent variables because they can cause a change in the dependent variable. The independent variable is the infection rate in the selected wards.

The independent variable of the study was the use of alcohol base hand sanitizer and hand washing using the standard protocol. The dependent variables were hand compliance rate and the HAIs rate in the selected units.

The dependent variable is this study is hand hygiene compliance rate. This is because the hand hygiene compliance rate can increase or decrease based on the practices and perceptions of the nurses. The independent variables in this study are the nurse’s practice and perceptions that are likely to cause a change in hand hygiene compliance either by causing an improvement or a poor compliance. In the study, there are three different practices and perception hence the there are three independent variables: practical hygiene, risky business and hygiene on trial.

Measurement

Identify primary statistics used

Incidences of healthcare associated infections were estimated using prevalence-to-incidence conversion methods. Mortality and LOS were

Pearson's Chi-Squared Test for independence was used to analyze the data for statistical significance with the level of significance established at

In the study, Standard deviations with t-tests, and proportions with chi-squared tests were used for bivariate analyses. To compare the hand hygiene compliance during

The study analyzed the collated data using an interpretative phenomenological analysis methodology to capture the nurse’s practices and perceptions

to answer clinical questions (You need to list the actual tests done).

analyzed using Cox regression and multistate mode this help prevent confounding biases. Multivariable Cox proportional hazards models were employed in comparing the death risk associated with HAIs as against patient without any infections.

p<0.05. pre- intervention and intervention period, Poisson regression analysis was used. Statistical analysis of the collated data was done using statistical Analysis System, version 9.3.

regarding hand hygiene. Commenting Microsoft Office software program was used in completing descriptive, linguistic and conceptual commenting.

Data Analysis Statistical or Qualitative findings

(You need to enter the actual numbers determined by the statistical tests or qualitative data).

The analysis shows that the highest overall prevalence of HAIs were seen in ICU patients with 32.7%, 95% CI 27.4–38.4. Also patient s with multiple invasive devices comes up with 47.9%, 95% CI 42.3–53.5.

After an adjustment was done for confounding and time dependent bias, the Cox regression shows that HAIs have an increased risk of mortality within 30 days with CI 0.7–2.4 and p=0.363).

Multistate model, revealed that HAI is found to increase LOS for a mean of 4.3 significantly The total point prevalence of patients with healthcare associated infection was 9.1% (95%

Chi-squared statistic result is 376.8 having two degrees of freedom and this resulted in a < 0.0005 p-wave. The statistical analysis results show that the reduction in HAIs seen in this research was highly significant.

For the study statistical significance was placed at p value of <0.05 and confidence intervals of 95% were reported. Statistical analysis for this study was conducted using Statistical Analysis System (SAS®) version 9.3 (SAS Institute, Cary, NC, USA). An estimate of 3% reduction in healthcare associated infection was projected after the intervention period having the level of significance at α = 0.05, and statistical power as β = 0.80.

Analysis of data revealed three deferent perceptions from nurses. These perceptions were used to form three super- ordinate themes; practical hygiene, risky business, and hygiene on trial. Recommendations associated with IPA were supported by 50% of the sample.

CI 7.8–10.6).

Findings and Recommenda tions

General findings and recommendati ons of the research

The study found out that there is an 80% increase in the daily risk associated with hospital death within the first 90 days of admission for patients with HAIs(HR 1.8, 95% CI 1.3–2.6). Having HAIs was seen to have increased the hospital length of stay with an average of 4.3 additional days. The study result showed that that the combination LRTIs, BSIs, and multiple concurrent healthcare associated infections doubles the risk of death among admitted patients as against patients surgical site infections and urinary tract infections with low risk of death. This study also showed that infections caused by microorganisms with tracer AMR phenotypes were shown to significantly increase the length of hospital stay by more than 2 weeks.

Findings for the study shows that Kikuyu hospital had a baseline hospital-acquired infection rate of 23.1% across the three wards and there was no incidence of healthcare associated infections during use of the alcohol base hand sanitizer. The staff was of the opinion that it is well tolerated and that it improved skin condition.

The study showed that there was improved compliance with hand hygiene during the intervention phase: hence, compliance with hand hygiene practices is feasible in resource limited settings with the provision of locally made alcohol base hand sanitizer. The finding also revealed that more preventive measures should be placed in operating and labor rooms mainly due to overcrowding. The researches recommended the need for more elaborate studies on how to integrate healthcare associated infection surveillance into routine hospital practices and to identify other ways to further prevent healthcare associated infection in areas with limited resources.

The study revealed the nurses practices and perceptions towards hand hygiene. It shows three theses namely practical hygiene, risky business, and hygiene on trial. The finding described the conflict experienced by nurses in regards to how they perceive their own hand hygiene practices and how the hospital management sees it. Other findings are that the participant expresses the difference between policy – mandated hand hygiene and personal sense of cleanliness. The researchers recommended the need for researchers and infection prevention specialists to consider ensuring nurses opinion is considered greatly when planning any hand hygiene improvement interventions.

Appraisal and Study Quality

Describe the

This study is a landmark study for the country of Greece because it is the first national data on the estimate of the prevalence and incidence of HAIs

The researchers chose controlled crossover design which is the right study design for the study. Crossover design removes the

This study is a breakthrough in the area of prevention of HAIs in areas with limited resources. It has proven that locally produced

The research ensured that nurses from different hospitals, departments, different years of experience and different part of

general worth of this research to practice.

What are the strengths and limitations of study?

What are the risks associated with implementatio n of the suggested practices or processes detailed in the research?

What is the feasibility of use in your practice?

in the country. This study will serve as a reference for other studies in the future.

On e of the strength of this study is that the result can be generalized in the whole of Greece. This is because the researchers selected a large sample size and at the same time ensured that all the various levels of hospital is represented, all the districts and regions in Greece were also represented.

There was no global surveillance data in Greece which made the researchers to refer to just the national point prevalence survey. Also data for this study were collected by observation leaving room for errors by omission.

This study is peculiar to Greece and so might not be applicable to my facility

effect of confounding covariates because each participant serves as it own control (Sibbald & Roberts,1998).

The study ensured that the validity is maintained by allowing a “wash out” period before switching the participants.

The result of this study is on the This “recommendation” level hence there is need to be at alert when applying it in my practice. If there is a multiple consistent result from other studies to collaborate this study then it is strongly recommended and can be applied without reservation.

alcohol can prevent the incidence of HAIs and also improve hand hygiene compliance. The study was carried out in a single locality and with simple and after research design due to financial issues. This might impact on the generalization of the result. Secondly, the hand hygiene compliance rate was measured by direct observation and this might be the reason why the compliance rate improved as the participants knows they are being observed. This study is a level three evidence hence its application is just a recommendation. It can be applied in a different hospital but with caution. The result of this study might not be applicable in my practice due to the observed limitations of this study.

the country were selected. This is to ensure that diverse perceptions were gotten and it gives strength to the study

One weakness of this study is the only eight participants were used for the study; hence the study finding represents the perception of few nurses.

The findings of this study cannot be applied because it lacks validity and hence cannot be adopted in my practice.

Key findings

Study findings showed that the incidence of HAIs, alongside its associated impact on length if hospital stays and mortality, poses a burden to the Greek healthcare

This research study demonstrates that the introduction of alcohol- based hand sanitizer can reduce HAIs.

The study showed that healthcare associated infection can be prevented using locally produced alcohol based hand sanitizer in a resources limited environment.

Three deferent perceptions from nurses were elicited. These perceptions were used to form three super-ordinate themes; practical hygiene, risky business,

system. This led to the suggestion that there is need for a systematic intervention to reduce the incidence of HAIs.

and hygiene on trial.

Outcomes

There is need to combat the increasing incidence in HAIs in Greece.

No HAIs were reported during use of the alcohol-based hand sanitizer

There was a reduction in the incidence of HAIs in two of the wards except in the labor room. The increased incidence in HAIs in labor room was attributed to increased traffic.

Nurse’s perceptions and practices in regard to hand hygiene and hand hygiene compliance was elicited.

Critical Appraisal on best Practice for the Prevention of Healthcare-Associated Infections

Healthcare-associated infections (HAIs) are becoming a severe problem in healthcare as it has attracted concerns from health

professionals, insurance companies, regulation bodies, and the government. According to Stone (2013), approximately two million

patients in the United States contract healthcare-associated infections, and about 90,000 of these patients are expected to die from it.

Annually, in the US, between 28 billion to 45 billion dollars are spent treating and settling legal issues associated with HAIs. HAIs place

a huge burden on the patients, increasing the cost of treatment, length of hospital stay, and causing avoidable deaths; hence the need to

prevent HAIs at all costs (CDC, 2013).

These analyzed articles have excellent practices for the prevention of HAIs, intending to improve pt outcome. Kampiatu and

Kozan (2015) provided the best practice in the prevention of HAIs with the use of alcohol-based hand sanitizer. In their studies carried

out in Kikuyu Hospital, one of the foremost tertiary hospitals in East Africa, the study showed that the hospital has a baseline HAIs of

23.1% in the three selected wards. The study adopted a cross-over design to compare the efficacy of alcohol-based sanitizer in preventing

HAIs compared to handwashing with soap and water. The result proved that there was no incidence of associated healthcare infections

during the use of the alcohol-based hand sanitizer, and the staff believed that it is a well-tolerated and improved skin condition. The use

of alcohol-based hand sanitizer in the prevention of HAIs is supported by Saito et al. (2017), who in their study result showed evidence

on the efficacy of alcohol-based hand sanitizer in the prevention of HAIs.

Pickering et al. (2010), in their study titled "efficacy of alcohol hand sanitizers compared with handwashing with soap and water,"

also proved that the use of alcohol-based hand sanitizer resulted in 0.64 to 0.82 log reduction per hand of E.coli compared to

handwashing with soap which showed 0.25 to 0.3 log reduction.

The use of alcohol-based hand sanitizer is provided a better practice because it is cost-effective, easy to implement, and increases hand

hygiene compliance because it can be carried around and be used on the go (Pittet, 2013).

References

CDC (2013) Public health focus: surveillance, prevention and control of nosocomial infections. Mmwc morb.mortal.wkly Rep.

2013 (42):783-787

Kampiatu, P., & Cozean, J. (2015). A controlled, crossover study of a persistent antiseptic to reduce hospital-acquired infection.

African journal of infectiousdiseases, 9(1),69.https://doi.org/10.4314/ajid.v9i1.2

https://doi.org/10.4314/ajid.v

Pickering, A. J., Boehm, A. B., Mwanjali, M., & Davis, J. (2010). Efficacy of waterless hand hygiene compared with handwashing

with soap: a field study in Dar es Salaam, Tanzania. The American journal of tropical medicine and hygiene, 82(2), 270–278.

https://doi.org/10.4269/ajtmh.2010.09-0220

Pittet D. (2001). Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerging infectious diseases, 7(2),

234–240. https://doi.org/10.3201/eid0702.010217

Stone, P. W., Braccia, D., & Larson, E. (2005). Systematic review of economic analyses of health care-associated infections. American

journal of infection control, 33(9), 501–509. https://doi.org/10.1016/j.ajic.2005.04.246

* These levels are from the Johns Hopkins Nursing Evidence-Based Practice: Evidence Level and Quality Guide

 Level I Experimental, randomized controlled trial (RCT), systematic review RTCs with or without meta-analysis

 Level II Quasi-experimental studies, systematic review of a combination of RCTs and quasi-experimental studies, or quasi-experimental studies only, with or without meta-analysis

 Level III Nonexperimental, systematic review of RCTs, quasi-experimental with/without meta-analysis, qualitative, qualitative systematic review with/without meta-synthesis

 Level IV Respected authorities’ opinions, nationally recognized expert committee/consensus panel reports based on scientific evidence

 Level V Literature reviews, quality improvement, program evaluation, financial evaluation, case reports, nationally recognized expert(s) opinion based on experiential evidence

**Note on Conceptual Framework

 The following information is from Walden academic guides which helps explain conceptual frameworks and the reasons they are used in research. Here is the link https://academicguides.waldenu.edu/library/conceptualframework

 Researchers create theoretical and conceptual frameworks that include a philosophical and methodological model to help design their work. A formal theory provides context for the outcome of the events conducted in the research. The data collection and analysis are also based on the theoretical and conceptual framework.

 As stated by Grant and Osanloo (2014), “Without a theoretical framework, the structure and vision for a study is unclear, much like a house that cannot be constructed without a blueprint. By contrast, a research plan that contains a theoretical framework allows the dissertation study to be strong and structured with an organized flow from one chapter to the next.”

 Theoretical and conceptual frameworks provide evidence of academic standards and procedure. They also offer an explanation of why the study is pertinent and how the researcher expects to fill the gap in the literature.

 Literature does not always clearly delineate between a theoretical or conceptual framework. With that being said, there are slight differences between the two.

https://www.hopkinsmedicine.org/evidence-based-practice/_docs/appendix_c_evidence_level_quality_guide.pdf

https://academicguides.waldenu.edu/library/conceptualframework

References

The Johns Hopkins Hospital/Johns Hopkins University (n.d.). Johns Hopkins nursing dvidence-based practice: appendix C: evidence level and quality guide. Retrieved October 23, 2019 from https://www.hopkinsmedicine.org/evidence-based-practice/_docs/appendix_c_evidence_level_quality_guide.pdf

Grant, C., & Osanloo, A. (2014). Understanding, Selecting, and Integrating a Theoretical Framework in Dissertation Research: Creating the Blueprint

for Your" House". Administrative Issues Journal: Education, Practice, and Research, 4(2), 12-26.

Walden University Academic Guides (n.d.). Conceptual & theoretical frameworks overview. Retrieved October 23, 2019 from https://academicguides.waldenu.edu/library/conceptualframework

https://www.hopkinsmedicine.org/evidence-based-practice/_docs/appendix_c_evidence_level_quality_guide.pdf

https://academicguides.waldenu.edu/library/conceptualframework