Journal of Prevention and Infection Control Open Access

Introduction

Hospital-acquired infections (HAIs) are major issues in healthcare settings, especially in the hospitals. HAIs pose safety concerns for healthcare workers (HCWs) and patients [1]. Hospital infections may cause a negative impact on healthcare costs with increased length of stay (LOS) and financial burden. HAIs also have a detrimental effect on morbidity and mortality. Additionally, HAIs can increase resistance to antibiotics, while leading to longterm disability [1]. HAIs also cause complications including sepsis. HAIs are preventable and crucial steps are needed to provide a safe patient environment. HAIs or nosocomial infections are patient infections obtained in a healthcare facility while receiving medical management (Centers of Disease Control and Prevention (CDC). HAIs are infections that occur after 48 hours of admission to a facility or within 30 days after patient discharge [2]. The primary categories include ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI), central-line associated bloodstream infection (CLABSI), and Clostridium difficile infection (CDI) [3]. These infections can be transmitted via fomites.

Fomites are porous and nonporous objects that can be contaminated with pathogens. Fomites can present as vehicles in HAI transmission [4]. Fomites include hospital environment surfaces and patient care items. These items can be frequently contaminated by pathogens. Examples of fomites are stethoscopes, wheelchairs, tourniquets, electrocardiography lead wires, computer keyboards, mobile phones, tablets, thermometers, and hand soap or sanitizer dispensers. These fomites can serve as carrier for infections. Pathogenic microorganisms that are responsible for causing HAIs are bacteria, fungi, parasites, and viruses. Bacteria is the most common pathogen responsible for causing HAIs. Acinetobacter is a pathogen that causes infection in the intensive care unit (ICU). Acinetobacter organisms are found in soil and water, which explains 80% of infections that are reported [5]. Clostridium difficile (c-diff) is also a very common pathogen implicated in HAIs. C-diff can be transmitted through an infected patient to others via HCWs from improperly cleansed hands. Escherichia coli, Staphylococcus aureus (that includes methicillin-resistant S. aureus (MRSA)) are also frequently found hospital pathogens. Pathogens can be transmitted during patient care interaction such as direct contact with patients through saliva, hands, and body fluids; or through HCWs or other sources in the environment.

The CDC (2018) updated the HAI data and statistics and reported that in 2015, there were an estimated 687,000 HAIs in US hospitals. In addition, there was about 72,000 reported mortality of patients who had HAIs during their hospitalization (CDC, 2018). HAIs cost over $30 billion annually in US healthcare [2]. HAIs are fiscally very costly accounting for billions of healthcare expenditures yearly in the US [6]. The CDC recommended steps for HAI control and prevention to decrease HAIs. Healthcare providers can help prevent HAIs by utilizing hand hygiene (HH) prior to and after each direct patient contact by the HCWs with appropriate disinfection can decrease HAI risk (CDC, 2018). Infection control (IC) interventions can be beneficial and costeffective [1]. Therefore, implementing IC interventions and following national guidelines for IC compliance to improve HAI incidence is essential.

Gap in Clinical Practice

HAIs are one of the leading issues in healthcare that are preventable. HAIs affect one in ten patients who are hospitalized. HAIs are linked to significant morbidity and mortality, as well as increasing financial burden not only to healthcare organizations (HCOs), but also to patients [7]. HH compliance and hospital disinfection is an increasing concern with their associated risk of HAI transmission. HH which does not comply with CDC recommendations was also found to be accountable for 40% of infections that are transmitted in the hospital, and surveys showed that enhancing compliance of HH significantly decrease HAIs [7]. On average, the CDC has estimated that HCWs follow HH guidelines less than half as frequently as they should (Brockway, 2018). There has been a tremendous emphasis on IC interventions with goals to decrease HAIs. However, research demonstrated a gap in HCWs’ knowledge regarding fomites as vessels of transmission of pathogens, as well as practices to decrease this transmission. Having enough knowledge is not effective unless the knowledge is properly applied through IC practices [4].

Patients traditionally have been passive in advocating for HAI prevention due to different levels of knowledge and concerns about infections; not receiving adequate information about IC and HAIs; and having the need for more awareness in terms of personal hygiene [8]. Seale and colleagues demonstrated that some patients were not likely ever to question HCWs about their IC behaviors due to feeling intimated, embarrassed, or reluctant, and other reasons of not engaging with the HCWs. Patients have expressed anxiety talking about IC. Although 80% of patients were willing to assist the HCWs with IC and prevention (ICP), many did not feel comfortable saying something to HCWs such as hand sanitizing [9]. There was also a low ICP compliance that resulted in high incidence of HAIs, which indicated that changing attitudes is the best prevention for transmission of infection [10].

Despite compelling evidence showing IC interventions help reduce the incidence of HAIs, there is still a large gap of knowledge, attitudes, and application of behaviors through IC compliance among HCWs. Further exploration about this concern is crucial. Implementing IC interventions to target the increasing HAI burden and consequences and evaluating the effectiveness of such measures in terms of improvement in HAIs is also needed.

Purpose of the Quality Improvement Project

The goal of the project improvement was to implement a quality improvement (QI) project on IC interventions to improve compliance in HH, routine fomite disinfection (FD), and environmental decontamination (ED) among HCWs. Inadequate HH, FD, and ED compliance can have significant potential contributions to HAI transmission. The project also aimed to evaluate the effectiveness of these IC measures. The ultimate goal was to reduce the incidence of HAIs, thus improving patient outcomes and quality of care.

Review of Literature

The literature review was conducted using Samuel Merritt University library and search engine such as Google. Literature search terms used were HAIs, fomites, infection control interventions, hand hygiene, hospital disinfection, and environmental decontamination. There have been multiple studies showing potential fomites that are contaminated with disease-causing pathogens; studies on IC interventions to improve the incidence of HAIs; and assessing knowledge about IC practices [1]. conducted a descriptive cross-sectional study to assess the knowledge, attitudes, as well as the practices of HCWs about infection transmission. The investigators found a substantial gap in knowledge of fomites by the HCWs as a possible source of transmission of microorganisms and practices to decrease spread conducted a cross-sectional study investigating the white coat contamination prevalence with vancomycin-resistant Enterococci, MRSA, and methicillin-sensitive S. Aureus. Large proportion of the white coats worn by HCWs was contaminated with hospital pathogens including MRSA. The investigators also found that white coats may be a significant source for patientto- patient S. Aureus [11]. Conducted an interventional study design (prospective before-and-after study) evaluating the effectiveness of implementing multifaceted IC interventions and antibiotic stewardship program on HAIs. Multifaceted IC interventions are found to be effective in decreasing the rate of HAIs, improving antibiotics’ rational use and HH compliance, which may decrease mortality in children that are hospitalized in developing countries [12]. A systematic review was conducted by Haun, Hooper-Lane, and Safdar to examine the HCWs’ attire and commonly used device with bacterial contamination. Stethoscopes, white coats, digital devices, and neckties were found to be frequently contaminated with bacterial pathogens, which includes S. aureus (including MRSA), and gram negative rods. Further studies are needed to explore the relationship of HCW’s attire and device with clinical infection [13]. Prospective, randomized controlled trial by Burden Compared the level of bacterial contamination (that includes MRSA) of the physicians’ white coats and the standardized newly washed short-sleeved uniforms. Contamination of bacteria just within hours of putting the newly laundered uniforms was reported [6]. There was no difference in the level of bacterial contamination of these uniforms compared to the physicians’ white coats that were infrequently laundered 8 hours later [6]. A prospective singleblinded study (before-and-after trial) by Schroeder, Schroeder, and D’Amico [14]. Investigated whether scrubbing the hands simultaneously with cleaning the head of the stethoscope with alcohol-based foam would markedly decrease the stethoscope’s bacterial count. Simultaneously washing hands with hand foam and cleaning stethoscope decreased the stethoscope’s bacterial counts. Schroeder conducted a prospective study aimed to investigate the bacterial contamination rate of mobile phones of HCWs compared to the control group (non-HCWs’ phones). There were 100% contamination of mobile phones and the hands of the staff.

Infection Transmission

Hand hygiene compliance

HAIs are commonly viewed to be related to poor hand washing compliance. Hand washing is largely accepted as the main IC intervention, especially in the ICU. There are reported factors causing poor compliance among HCWs in terms of HH. Factors include irritation of the skin from the HH agents, limited materials, staff issue such as understaffing with high nurse-topatient ratio and high patient care acuity, and other factors [15].

Fomite disinfection.

There are many potential fomites, especially in healthcare. Fomites include stethoscopes, pens, bedside tables and bedside rails, thermometers, and computers including keyboards and mice and hospital phones and pagers. Other potential objects include identification badges, purses, uniforms, and rings have also been. Clothing contamination such as white coats and uniforms that are worn by HCWs are also found to be potential vectors for infection transmission. Hand sanitizer dispensers also have the potential for pathogen contamination. Evidence showed that stethoscopes and otoscopes were found to have 100% and 90% bacterial colonization, with MRSA found in 7.3% of stethoscopes and 9.5% in otoscopes. The reasons why HCWs do not clean stethoscopes prior and after each patient care is having lack of time, too busy, and forgetting to clean the stethoscopes in the emergency department (ED).

Environmental De-contamination

The hospital environment is also found to be contaminated by pathogens. Viruses, bacteria, and fungi can survive in inanimate hospital environment. IC measures that include environmental cleaning is important to get rid of potential disease-causing viruses including influenza and Para influenza. Hospital surfaces were found to be harbored by contaminants such as MRSA and VRR. C-diff and other pathogens are resistant to regular cleaning agents. Disinfection is an important ED method. There are different disinfecting solutions to control HAI transmission, with increased focus on IC HH measures.

Change Model: The ADKAR (awareness, desire, knowledge, ability, reinforcement) model was the change management framework for this project. Awareness that change was needed; desire of the staff to support such change; knowledge of how to bring about change; ability to apply the knowledge and skills; and reinforcement to maintain the change. ICP was a vital part of hospital safety measures. The critical goal was to make the staff understand and realize that change was needed to improve HAIs (awareness). However, challenges can arise when implementing a change in any setting [16-20]. Staff may resist such change or may even have passive reactions. This is why the desire of the staff was crucial to participate in the change management. Unit leaders also have a critical role in helping the staff get involved in the change such as improving compliance with IC. Educating the staff on multiple areas of ICP will provide them with the knowledge and ability on how to reduce HAIs and also improving IC compliance. Reinforcement is ensuring that staff will continue to practice good ICP measures. ICP is a continuous process and providing feedback from the unit leaders is important to ensure success of the change process.

Methods

The research project proposal was submitted to Samuel Merritt University Institutional Review Board (IRB) and the project site IRB. It was determined that IRB review or authorization was not required. Approval from the stakeholders including the unit leaders was also obtained prior to project implementation.

Design

The study used a repeated measures design. Monthly data were retrospectively collected for six months before and three months after the intervention was implemented. However, due to time constraint, post-intervention was reduced to two months instead of three months.

Setting

The project took place in a step down unit of a magnetdesignated hospital located in California. It was a busy unit with a 36-bed capacity. The unit provided cardiac and medical patient management care including pharmacological treatment and ventilator support.

Sample/Participants

The sample for the HAI data collection was adult-geriatric patients who were admitted in the unit. Inclusion criteria included admitted patients in the unit for more than 48 hours, ≥18 years of age, and diagnosed with an acute medical and/or cardiac condition. Data associated with patients with known or suspected infection(s) upon admission were excluded. Exclusion criteria also included patients who were transferred from other units with suspected or confirmed HAI, and those with dialysis catheters since the staff from other units did not receive educational training on IC. Additionally, the unit staff did not access these types of central lines, and dialysis nurses who provided dialysis catheter site care in the unit were from a different department [21-26]. The IC interventions were carried out by HCWs in the unit, such as the registered nurses (RNs) and clinical care partners (CCPs).

Data

The outcomes of the study were listed in Table 1 with the variable names, operational definitions, and measurements. To measure intervention fidelity of HH, FD, and ED compliance, the numerator consisted of the directly observed HH actions of HCW (for the HH compliance), directly observed FD actions (for the FD), and the high touch wipe down (HTWD) recorded by the CCPs. A checklist was made for each observation. The denominator of the three interventions consisted of the total number of items in the checklist. The numbers obtained from each intervention were multiplied by 100 to obtain meaningful results.

WHO Observation Tool

There has been a major emphasis on promoting HH in healthcare. In 2005, the first Global Patient Safety Challenge entitled “Clean Care is Safer Care” was launched. As part of the initiative, the WHO created HH guidelines including Multimodal HH Improvement Strategy (MHHIS) (TJC, 2010). The WHO has 5 Moments of HH that recommends “moments” or times when the HCWs should clean their hands. This approach consisted of HH: (1) prior to touching a patient, (2) before performing clean or aseptic procedures, (3) after risk or exposure to body fluid, (4) after touching the patient, and (5) after touching patient environment. The WHO Guidelines on HH in Health Care have been created with the objectives to change HCW behavior to improve compliance with HH using the 5 Moments of HH. The ultimate goal was to improve patient safety. The WHO MHHIS has a Guide to Implementation with a variety of tools to assist with fostering improvement in HH in HCOs.

Numerous auditing tools for HH existed and most of these tools have been widely tested. These tools were also available online for public use and can be considered for use by any HCO. WHO Observation Tool is the most widely used tool to monitor HH compliance. The WHO Observation Tool is a user-friendly and a quite sophisticated tool. The tool has been translated into multiple languages and has been validated extensively. The observation tool has also been used as an instrument development model for the promotional campaigns of HH in over 25 countries [27]. The tool collects data at each HH opportunity. For each opportunity, HH indication associated with the five moments is recorded.

The WHO Observation Tool was used to monitor HH compliance. FD tool can also be found in Figure 1.

Direct Observation

There are multiple ways to monitor HCW compliance in terms of IC behavior such as HH. Direct observation (DO) is considered to be the gold standard in monitoring HH compliance. It is the recommended standard practice by the WHO to monitor adherence. Monitoring compliance is an essential quality indicator in HCOs to prevent HAIs. However, DO have limitations including inter observer variation and the potential for Hawthorne effect. Hawthorne effect is an observer effect the cause’s modification of behaviors among participants in IC intervention or epidemiological studies due to the knowledge of being watched. Other potential biases include selection, observer, and observation bias. DO can also be costly and labor extensive. It requires careful selection and training of the observers. Secret observers are also great resources to minimize the potential for Hawthorne effect.

The DO method was used to monitor compliance in HH, FD, and ED among unit staff. This was used as a basis to evaluate effectiveness of IC measures.

Data collection

Pre-intervention data consisted of six-month retrospective HAI data. Data was also collected post-intervention for comparison.

Outcome measures

HH compliance, routine FD, and ED were assessed and evaluated during the intervention period since these measures were new to the staff (except for the HTWD that was considered a part of the ED), and reassessed post-intervention to evaluate the effectiveness of IC interventions using HAI rates, as well as evaluate improvement in IC practice with the three interventions. The HAI rates were the main outcome of the study.

Procedures

Intervention measures

Pre-intervention Period: During the pre-intervention period, the project was discussed in detail with the stakeholders such as the senior nurse scientist, practice mentor, unit leaders, and the unit staff. The author served as the DNP project manager. Initially, two staff from the day shift and two staff from the night shift were recruited to be the secret observers. They were tasked to perform the DO of the unit staff to monitor their compliance with HH, FD, and ED. The DO method by Magnus was used as a guide. The observers were trained on how to properly observe HH. Training included showing videos that include scenarios where HCWs have opportunities for assessing. The training film by the WHO was not available for use, so the PowerPoint slides that explained the content of the film was used for training purpose instead. The ED has already been practiced in the unit for some time by the CCPs. The unit also had a specific form where the HTWD record can be found. Secret observers were utilized to prevent the potential for Hawthorne effect [28].

Online Survey: Assessment of IC practices was obtained from the staff through online survey Figure 2. There were six questions that focused on the importance of IC, and the IC practices of the staff with HH, FD, and ED. Incentives were provided to the first 30 respondents (Starbucks gift card) to increase participation. There were 42 respondents for the survey.

Analysis of the Survey: Based on the survey, it showed that majority of the respondents placed a very important role on ICP at work. For the HH practices, majority of the respondents always perform HH, some staff usually perform HH, and a very few sometimes perform HH with the 5 Moments of HH. For the third question, it seemed that there was some lack of knowledge regarding the duration of HH, only 31.71% answered the question correctly (minimum of 20 seconds). For stethoscope disinfection, there was a disagreement between the staff. Majority always disinfect their stethoscopes before and after patient use, some staff usually do it, very few sometimes do it, and one staff answered to never disinfect stethoscope before patient use. For disinfecting phones, pagers, glucometers, and other potential carriers of infection, less than half of the respondents always and usually disinfect these fomites (19 and 15 respectively), and one staff responded to never disinfect fomites. For the HTWD for ED, less than half always and usually perform HTWD (18 and 12 respectively) and three respondents answered that they never perform HTWD.

Intervention Period: The project was implemented on June 01, 2019 to August 31, 2019 for three months. During the intervention period, educational teachings regarding IC measures were provided to the staff. Active engagement of the staff was also encouraged. Staff education was provided through shift huddles, weekly unit reminders, and announcements in the unit. A weekly and monthly performance feedback was discussed to monitor progress. Education materials that include posters, pamphlets, printouts, and laminated materials covered the topics of ICP, HAIs and types of HAIs, fomites and potential for cross-contamination, HH highlighting the 5 Moments of HH by the WHO, and the importance of HH, FD, and ED. Pamphlets were disseminated to the unit staff. A weekly reminder through emails and day/night mid shift huddles were included to ensure compliance with the interventions and ongoing education. Reminders were also placed on each patient’s pod to remind staff to perform HH, disinfect stethoscopes, glucometers, and other potential fomites before and after each patient encounter using bleach wipes. Clorox bleach wipes and two types of Sanitary-Cloth wipes were the three surface disinfecting wipes approved for use at the hospital. Alcohol wipes do not completely eradicate the microorganisms that can be found in the stethoscopes or other fomites. Phones and pagers were disinfected with bleach wipes before and after each shift by the resource nurse, and as needed by the staff if risk of contamination was observed. Alcohol hand sanitizer dispensers and ABHR were also available outside of every patient room for use by the staff. There was also individual sink in every patient room for hand washing. For the ED, the CCPs disinfected the high touch areas in each patient’s rooms with Bleach wipes at the beginning of e ach shift [29-34].

The intervention process included recording measurements of the IC interventions using three audit tools. HH was measured using the WHO Observation Tool while incorporating the 5 Moments of HH. The FD measurement tool was created by the primary investigator, but also incorporating the same principles of HH. This measured the directly observed FD actions such as disinfecting the stethoscopes and glucometers before and after patient use; and the phones and pagers before and after each shift and as needed. The measurement also included recording the type of disinfectant that was used for FD. The high touch patient room surfaces included the bedrails, bedside table, intravenous (IV) pumps and poles, patient television, computer-on-wheels, sink, call light button, and light switch.

The intervention period was broken down into weeks in terms of educational teachings:

A. Week 1-3 – general teaching regarding IC including the 5 Moments of HH by the WHO, HH, FD, and ED. DOs of IC practices were also documented.

B. Week 4-6 – staff teachings on how to properly perform HH (hand washing and ABHR) with the visual images by the WHO during huddles. Clarification regarding the disinfecting wipes used for HTWD by the CCPs and fomites were also discussed with the IC specialist, staff, and the unit leaders. This included the type of disinfecting wipes used for HTWD and FD. Continued DOs of IC practices were documented.

C. Week 7-8 – the staff were given printed stickers of the CDC “Clean hands count (ask me if I cleaned my hands) to be placed on their uniforms to remind them of HH. Education on the importance of good IC practices throughout the intervention period continued [35].

The staff was also asked to write names of those who have done an outstanding job with IC practices. This was to increase their participation with IC measures and to motivate all staff to incorporate good IC practices into their habit. Every month, one to two staff who did an exceptional job practicing good IC such as doing hand washing, disinfecting potential fomites, or HTWD were recognized and given incentives. Stressing the importance of IC and further education were also provided during the quarterly staff meeting in which PowerPoint slides were presented to the staff.

D. Week 9-11 – Due to few cases of CLABSI, CLABSI education was provided to the staff during huddles and one-to-one education including CLABSI care bundle and maintenance care from the Association for Professionals in Infection Control and Epidemiology (APIC), TJC (2013) “Scrub the hub!”.

E. Week 12-13 – ongoing IC intervention including CLABSI prevention, “gel in” and “gel out” with ABHR during huddles and one-to-one education. Staff was encouraged to continuously acknowledge co-workers who exemplify a great job with ICP. This project can be replicated based on the above intervention steps.

Post intervention Period: The post-intervention period consisted of continued observation of IC measures such as HH, FD, and ED. The post-intervention lasted for two months from September 01, 2019 to October 31, 2019. To evaluate for compliance with HH in addition to the WHO Observation Tool, the Glo Germ™ tool was used. The Glo Germ™ is a visual teaching tool to evaluate for proper hand washing technique. A Glo Germ lotion rubbed into the hands “simulate germs”. After washing hands, a UV light was used to reveal a glow that turned the invisible into “germs you can see!” (GloGerm™ (n.d.). Residue (bright white spots in the hands) from the Glo Germ™ lotion indicated that the staff did not effectively perform hand washing [36-40]. The Glo Germ TM UV light showed areas of the hands that were not washed properly. Additionally, to evaluate compliance with ED, a masking spray was used to spray the high touch patient care areas prior to HTWD by the CCPs. The UV black light was then used to check if the areas were completely disinfected. Similar to the Glo Germ™, it also showed residue(s) if the areas were not properly disinfected with Clorox bleach wipes.

Consent: Informed consent was obtained from the unit leaders and staff.

Risks: There was a minimal risk associated with the IC measures, such as loss of confidentiality. Patients were not directly involved in the project nor there direct treatment. However, monthly reporting of HAI patient data was collected. The unit staff were monitored and directly observed in measuring IC intervention compliance.

Benefits: There may be no direct benefit to the participants in this study. However, potential benefits include adherence to IC interventions and the understanding, awareness, and information achieved from this study can significantly improve HAI incidence. This can also improve patient outcomes as reduction in HAIs can prevent further complications such as sepsis and other consequences. Reduction in HAIs can lead to decreased healthcare costs and improved reimbursement rate from payers, having a significant financial impact to the organization.

Costs/Payments: There was no cost to the unit staff to participate in the study, and no payment was made, however there were incentives given to the staff to increase participation.

Confidentiality: The identity of the unit staff was kept anonymous and confidential. However, the job titles were indicated to distinguish roles between the HCWs. Patient confidentiality were protected under the HIPAA law. Patient medical records were not accessed, however, mini root cause analysis of unit HAI cases were provided and reviewed with the Practice Mentors to assess if the HAI cases fall into the exclusion criteria.

Conflict of Interest: There was no financial conflict of interest disclosed.

Data Analysis: A paired sample t test was used to analyze IC compliance data. Spearman Correlation analysis was used to evaluate the strength of relationship between variables. To measure the internal consistency or reliability of the WHO Observation Tool, Cornbrash’s alpha α was used. A p value of < 0.05 denotes a statistically significant result.

For the purpose of this project, HAI data during intervention period was included in the post-intervention HAI data. Retrospective six-month HAI data was collected pre-intervention for comparison. During the post-intervention period, another monitoring of HH, FD, and ED similar to that of the intervention period were assessed and the results were compared to the intervention data to evaluate the effectiveness of IC interventions [40-42]. IC run charts were utilized to observe monthly HAI trends from the pre-intervention to post-intervention periods. Data analysis was performed using SPSS version 26 and Intellects Statistics.

Results

Baseline HAI data

HAI data was collected from the months of December 2018 to May 2019. There were two CAUTIs, one CLABSI, and seven CDI during the pre-intervention period – total of ten HAI rates [43]. The standardized infection ration (SIR) developed by the CDC’s National Healthcare Safety Network (NHSN) was used to measure incidence of HAIs. The SIR was used by the project site to track their HAI rates. It was measured by dividing the number of observed HAIs over the number of predicted HAIs Table 2.

Post-intervention Period

CAUTI: There has been one reported case of CAUTI. However, this patient was transferred from another unit where the Foley catheter was placed. Additionally, the wound care team has been strictly collaborating with the unit and strongly oppose placement of indwelling catheterization; and if catheterization should be attempted, they recommend straight catheterization instead. The most frequent cause of patient infections in healthcare facilities is attributed to indwelling urinary catheter use (CAUTI). Evidence showed that intermittent catheterization is beneficial over indwelling catheterization in reducing CAUTI rates. It is also reported that intermittent catheterization is one of the most effective and frequently used strategy in patients who are having urinary retention in terms of bladder management.

CLABSI: Data showed five CLABSI rates (during the intervention period). Interestingly, there were significant cases of CLABSI in the unit (total of five cases) during the intervention period. However, it was found that four cases have dialysis catheters used for either hemodialysis or apheresis which were not accessed by unit staff. Additionally, there was also an increased need for float staff in the unit since the unit was one of the busiest in the hospital because of high patient admissions/ discharges and complex patient care management [44-46].

CDI: Post-intervention data showed two CDI cases. The monthly HAI rates, specifically CAUTI, CLABSI, and C-diff were presented in Figure 3.

IC Intervention Compliance Rates

HH, FD, and ED compliance rates for the IC interventions are found in Figure 4. FD compliance rate was difficult to assess compared to HH and ED due to difficulty observing staff with disinfecting potential fomites such as glucometer, stethoscopes, and phones/pagers. However, every shift, the resource nurse disinfected all phones and pagers at the end of the shift in preparation for the next staff use. Issues with the HTWD include having float CCPs who may not be aware of the HTWD in the floor; may not have done the HTWD; or may have not remembered documenting on the form. Some of the documentation forms were also incomplete. This may be due to CCPs not doing the forms, forgetting to submit the forms, or misplaced forms [42].

Discussion

There were total of 459 total HH opportunities and 383 actions (90 total sessions) in the intervention and post-intervention periods. Between the months of June to August 2019, there were 256 actions out of 319 opportunities (53 sessions) in the intervention period (t (52) = 3.288, p = .002, 95% confidence interval (CI; [.463, 1.914]). There were 127 HH actions out of 140 HH opportunities (37 sessions) during the post-intervention period (t(36) = 3.163, p .003, 95% CI [.126, .577]. An increase in HH compliance was found in the post-intervention period (90.7%) compared to the intervention period (80.3%).

During the post-intervention period, the HH compliance was evaluated using the Glo Germ™ UV light. There were 96 participants, and 70 RNs and CCPs (73%) were evaluated and they were able to demonstrate effective hand washing. ED with HTWD was also evaluated using the marking spray with UV light. Twelve out of 20 CCPs (60%) were also evaluated and they were able to demonstrate effective HTWD as evidenced by complete decontamination of high touch patient care areas.

A large effect size was obtained with a significant positive correction between the HH variables in the intervention period (r_s = 0.80, p < .001) and post-intervention period (r_s = 0.95, p < .001) (Intellects Statistics, 2017).

Using Intellects Statistics (2017), the WHO HH Observation Tool had a Cornbrash α of 0.78 (95% CI) in the intervention period indicating acceptable reliability and Cornbrash α of 0.96 in the post intervention period indicating excellent reliability.

\Intervention day shift ED showed 2192 HTWD out of 2214 opportunities (99.1%) and post-intervention showed 1729 HTWD out of 1737 opportunities (99.5%). Intervention night shift showed 1901 HTWD out of 1918 opportunities (99.1%), and post-intervention showed 1489 HTWD out of 1494 opportunities (99.7%). Due to lack of data, FD data were not analyzed.

HAI data showed one CAUTI case post-intervention. However, it was an ICU transfer and therefore excluded from the data. Additionally, despite the CLABSI outbreak, four cases were excluded following the exclusion criteria (presence of dialysis catheters). Unit staff was not accessing this type of central lines. Only hemodialysis or special nurses from different unit departments can only access the site during patient hemodialysis or apheresis. There were ten HAI rates during the pre-intervention period. During the post-intervention period, there were total of three HAI rates minus the excluded cases.

Data showed a significant improvement in HAI rates from pre-intervention to post-intervention period with 70% reduction from ten cases to three cases of HAIs. However, post-intervention phase was cut down to two months due to time constraints, to allow ample time for data analysis as explained in Table 3.

Conclusion

There were statistically significant improvements in hand hygiene compliance rates from intervention to post-intervention period. Given the excellent ED compliance rates throughout the intervention and post-intervention period (over 99% compliance) with no significant difference, data analysis was not performed. Due to lack of data, fomite disinfection data analysis was not calculated. Additionally, there was a 70% reduction in hospital-acquired infection rates. Initiation of HAI protocols with ongoing data collection would determine the true impact of infection control interventions on hospitalacquired infections.

This project has a major implication in healthcare especially that hospital-acquired infections are a major culprit for increased patient morbidity, length of stay, and mortality. Hospitalacquired infections also have negative effect on healthcare costs. These infections are preventable, and interventions are needed to reduce infection rates. Infection control and prevention is an effective strategy to minimize the risk of infection. Healthcare workers are the patient’s first line caregivers and it is our main responsibility as a part of the healthcare team to ensure that our patients are safe from harm. Hand hygiene, routine fomite disinfection, and environmental decontamination are basic infection control practices that we can incorporate in our daily routine to help prevent the transmission of infection. These are simple measures that can positively impact patient safety.

Limitations

There are few limitations of the study. The main limitation was the presence of Hawthorne effect. This was not minimized by the variability of visit schedule of the project manager to the unit at different times of the day and days of the week (including weekends and nighttime hours). It was also challenging to perform DO by the secret observers due to the high-acuity busy nature of the unit especially during the day, so the project manager was tasked to do the DO discretely. Due to this reason, the staff was aware that they were being audited for their infection control practices, thus skewing the data. The other limitation was staffing issues. Due to the high-acuity patient demands and patient volumes, the unit regularly utilized nursing staff from the float pool team to fill in the need. They were not unit staff and most of the time, they were not aware of the daily practices in the unit. This made it difficult to completely educate them and monitor their compliance especially that their full cooperation was difficult to obtain. Another limitation was the conflicting practices or miscommunication between the staff in terms of infection control early in the project implementation. Some of the staff uses Sanitary Cloth wipes (germicidal disinfecting wipes) to clean the glucometer and for the HTWD even though the hospital policy stated to use Clorox bleach wipes. Some CCPs also did not do HTWD on the IV pump (but cleaned around it and the IV pole) with the concern of making any change to the IV medication such as rate or possibly turning it off.

In terms of the sudden rise in the CLABSI cases during the intervention period, confounding variables may have influenced these infections. IC is a complex process and IC measures such as HH, FD, and ED are not all inclusive to completely eradicate risk for infection. There are also other factors such as patient comorbidities, immunosuppression, antibiotic use, or complex patient care needs among many others. These patients have higher risk for HAIs.

Acknowledgments

I would like to thank my project chair, Dr. Mary Wyckoff, who was also the co-author of this project, for being such an excellent teacher and for her continuous guidance, support, and feedback throughout the project. She offered great feedback and tremendous assistance in shaping and completing this project. I would like to acknowledge the stakeholders of the project site for their support in regard to the process of implementing the research project. Additionally, I would like to thank my practice mentors Ms. Susan Singh and Ms. Mary Nichols-Lawanson for their assistance in data collection and great feedback and recommendations to help improve this project. I also would like to thank the unit leaders for their full support of the project. Lastly, I would like to thank my fiancé Kevin Quinonez for being very supportive of my research project. I would not have done this project without his unconditional love and support knowing that this project would require a great amount of time away from family.

Funding

The costs incurred in the project implementation were personally paid by the primary author, AC. However, SMU will offset the expenses through reimbursement to the author.

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